Healthcare Provider Details

I. General information

NPI: 1144422577
Provider Name (Legal Business Name): OPTICAL 2000
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 HIGHWAY 80 E
CLINTON MS
39056-5252
US

IV. Provider business mailing address

815 HIGHWAY 80 E
CLINTON MS
39056-5252
US

V. Phone/Fax

Practice location:
  • Phone: 601-924-4444
  • Fax: 601-924-4100
Mailing address:
  • Phone: 601-924-4444
  • Fax: 601-924-4100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number00748
License Number StateMS

VIII. Authorized Official

Name: DR. BOBBY C PANKEY
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 601-924-4444