Healthcare Provider Details

I. General information

NPI: 1245621978
Provider Name (Legal Business Name): IJA DEVELOPMENT FIRM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2015
Last Update Date: 02/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123A HIGHWAY 80 E
CLINTON MS
39056-4738
US

IV. Provider business mailing address

123A HIGHWAY 80 E
CLINTON MS
39056-4738
US

V. Phone/Fax

Practice location:
  • Phone: 601-519-1709
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: INGRID ADAMS
Title or Position: DIRECTOR
Credential:
Phone: 601-519-1709