Healthcare Provider Details

I. General information

NPI: 1164556932
Provider Name (Legal Business Name): MULLIS EYE INSTITUTE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 COLLEGE BLVD W STE 4 TWIN CITIES MEDICAL BLDG
NICEVILLE FL
32578-1060
US

IV. Provider business mailing address

1600 JENKS AVE
PANAMA CITY FL
32405-4644
US

V. Phone/Fax

Practice location:
  • Phone: 850-678-5338
  • Fax: 850-763-6665
Mailing address:
  • Phone: 850-763-6666
  • Fax: 850-763-6665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberME0027750
License Number StateFL

VIII. Authorized Official

Name: O LEE MULLIS
Title or Position: PRESIDENT
Credential: MD
Phone: 850-763-6666