Healthcare Provider Details

I. General information

NPI: 1790916294
Provider Name (Legal Business Name): RHETTA A CONN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2009
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 CENTRAL AVE
COLDWATER MS
38618-3843
US

IV. Provider business mailing address

PO BOX 486 412 CENTRAL AVENUE
COLDWATER MS
38618-0486
US

V. Phone/Fax

Practice location:
  • Phone: 662-622-5173
  • Fax: 662-622-5590
Mailing address:
  • Phone: 662-622-5173
  • Fax: 662-622-5590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number806
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: