Healthcare Provider Details

I. General information

NPI: 1316020043
Provider Name (Legal Business Name): SOUTHERN EYE CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 N PATTERSON ST SUITE B
VALDOSTA GA
31602-2568
US

IV. Provider business mailing address

2310 N PATTERSON ST SUITE B
VALDOSTA GA
31602-2568
US

V. Phone/Fax

Practice location:
  • Phone: 229-247-2020
  • Fax: 229-247-5600
Mailing address:
  • Phone: 229-247-2020
  • Fax: 229-247-5600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT002069
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number025970
License Number StateGA

VIII. Authorized Official

Name: DR. MARK JOSEPH EANES SR.
Title or Position: PRESIDENT
Credential: MD
Phone: 229-247-2020