Provider Demographics
NPI:1073681532
Name:EYE CARE OF LELAND PA
Entity type:Organization
Organization Name:EYE CARE OF LELAND PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:W
Authorized Official - Last Name:STANFILL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:662-686-7871
Mailing Address - Street 1:PO BOX 106
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38756-0106
Mailing Address - Country:US
Mailing Address - Phone:662-686-2020
Mailing Address - Fax:
Practice Address - Street 1:206 BAKER BLVD
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:MS
Practice Address - Zip Code:38756-3402
Practice Address - Country:US
Practice Address - Phone:662-686-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS408152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016267Medicaid
MS09016267Medicaid
MSC04502Medicare ID - Type UnspecifiedGROUP NUMBER