1407029465 NPI number — SOUTHERN EYECARE, P.C.

Table of content: (NPI 1407029465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407029465 NPI number — SOUTHERN EYECARE, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN EYECARE, P.C.
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:
Provider Other Organization Name Type Code:
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:
1407029465
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P O BOX 430
Provider Second Line Business Mailing Address:
25 CROSS ST
Provider Business Mailing Address City Name:
HAZLEHURST
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31539-0430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-375-2516
Provider Business Mailing Address Fax Number:
912-379-0755

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 CROSS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAZLEHURST
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31539-6427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-375-2516
Provider Business Practice Location Address Fax Number:
912-379-0755
Provider Enumeration Date:
04/10/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MASON
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
LLOYD
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
912-375-2516

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT001506 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: OPT002403 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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