Provider Demographics
NPI:1962800011
Name:POPLARVILLE EYE CLINIC, LLC
Entity type:Organization
Organization Name:POPLARVILLE EYE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BETHANY
Authorized Official - Middle Name:G
Authorized Official - Last Name:HARRINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:601-795-0137
Mailing Address - Street 1:PO BOX 521
Mailing Address - Street 2:
Mailing Address - City:POPLARVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39470-0521
Mailing Address - Country:US
Mailing Address - Phone:601-795-0137
Mailing Address - Fax:601-795-0148
Practice Address - Street 1:1716 S MAIN ST
Practice Address - Street 2:
Practice Address - City:POPLARVILLE
Practice Address - State:MS
Practice Address - Zip Code:39470-4287
Practice Address - Country:US
Practice Address - Phone:601-795-0137
Practice Address - Fax:601-795-0148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS685152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880221Medicaid