Provider Demographics
NPI:1316113616
Name:COLLINS EYE CLINIC INC
Entity type:Organization
Organization Name:COLLINS EYE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:C. CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:601-638-2081
Mailing Address - Street 1:1206 MISSION 66
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-3137
Mailing Address - Country:US
Mailing Address - Phone:601-638-2081
Mailing Address - Fax:601-638-2171
Practice Address - Street 1:1206 MISSION 66
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-3137
Practice Address - Country:US
Practice Address - Phone:601-638-2081
Practice Address - Fax:601-638-2171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS522332H00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087003Medicaid
MS512G700191Medicare PIN
MSTN047EMedicare UPIN
MS00087003Medicaid