Provider Demographics
NPI:1316173842
Name:HEALTHY EYES FAMILY VISION CENTER LLC
Entity type:Organization
Organization Name:HEALTHY EYES FAMILY VISION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:LATRELL
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:601-957-3870
Mailing Address - Street 1:148 MANCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-2416
Mailing Address - Country:US
Mailing Address - Phone:601-957-3870
Mailing Address - Fax:
Practice Address - Street 1:4253 ROBINSON ST
Practice Address - Street 2:SUITE 105
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-6530
Practice Address - Country:US
Practice Address - Phone:601-922-9272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-10
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS745152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty