Healthcare Provider Details

I. General information

NPI: 1154677136
Provider Name (Legal Business Name): JOSHUA C MASSEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2012
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 HIGHWAY 80 E
CLINTON MS
39056-5246
US

IV. Provider business mailing address

929 HIGHWAY 80 E
CLINTON MS
39056-5246
US

V. Phone/Fax

Practice location:
  • Phone: 601-924-7274
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number854
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: