Provider Demographics
NPI:1427262450
Name:MS EYE CARE PA
Entity type:Organization
Organization Name:MS EYE CARE PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-446-9000
Mailing Address - Street 1:14994 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-2616
Mailing Address - Country:US
Mailing Address - Phone:662-773-3494
Mailing Address - Fax:662-773-7883
Practice Address - Street 1:6 PROFESSIONAL PLZ
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759
Practice Address - Country:US
Practice Address - Phone:662-323-3330
Practice Address - Fax:662-323-3880
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MS EYE CARE PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-09
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS492152W00000X
MS706152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05208871Medicaid