1962658203 NPI number — SEE SIDE OPTICAL INC

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 1962658203 NPI number — SEE SIDE OPTICAL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SEE SIDE OPTICAL INC
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:
1962658203
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5405 INDIAN HILL BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DIAMONDHEAD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39525-3324
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5405 INDIAN HILL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DIAMONDHEAD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39525-3324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-255-8585
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GREGORY
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT/DOCTOR
Authorized Official Telephone Number:
228-255-8585

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  574 , 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: 1962658203 . This is a "NPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 00880009 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1902060643 . This is a "NPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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