1366697799 NPI number — MISSISSIPPI EYE CARE ASSOCIATES OF JACKSON, PLLC

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 1366697799 NPI number — MISSISSIPPI EYE CARE ASSOCIATES OF JACKSON, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSISSIPPI EYE CARE ASSOCIATES OF JACKSON, PLLC
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:
1366697799
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 WEST WOODROW WILSON DRIVE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39213-7662
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-366-9020
Provider Business Mailing Address Fax Number:
601-321-3979

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 WEST WOODROW WILSON AVENUE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39213-7662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-366-9020
Provider Business Practice Location Address Fax Number:
601-321-3979
Provider Enumeration Date:
11/26/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BULLIN
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
TERRELL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
601-366-9020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  783 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332H00000X , with the licence number: 783 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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