1184742843 NPI number — MENDENHALL OPTOMETRIC EYE CLINIC, P.A.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184742843 NPI number — MENDENHALL OPTOMETRIC EYE CLINIC, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MENDENHALL OPTOMETRIC EYE CLINIC, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MENDENHALL EYE CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184742843
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P. O. BOX 577
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENDENHALL
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39114-3107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-847-1232
Provider Business Mailing Address Fax Number:
601-847-1376

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1021 EAST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENDENHALL
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39114-3107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-847-1232
Provider Business Practice Location Address Fax Number:
601-847-1376
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
WILLARD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
601-847-1232

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  423 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: C03245 . This is a "GROUP SUPPLIER CODE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 00087015 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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