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

Table of content: (NPI 1184742843)

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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