1306010897 NPI number — TINA SOREY DOCTOR OF OPTOMETRY, PA

Table of content: (NPI 1306010897)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306010897 NPI number — TINA SOREY DOCTOR OF OPTOMETRY, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TINA SOREY DOCTOR OF OPTOMETRY, PA
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:
SOREY 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:
1306010897
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
117 LUCKNEY STATION
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLOWOOD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39232-8027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-992-7275
Provider Business Mailing Address Fax Number:
601-992-7244

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 LUCKNEY STATION
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLOWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39232-8027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-992-7275
Provider Business Practice Location Address Fax Number:
601-992-7244
Provider Enumeration Date:
04/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SOREY
Authorized Official First Name:
TINA
Authorized Official Middle Name:
RENEE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
601-992-7275

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  637 , 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: 09015291 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com