Healthcare Provider Details

I. General information

NPI: 1982906509
Provider Name (Legal Business Name): GTREC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2010
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 ALABAMA ST
COLUMBUS MS
39702-5306
US

IV. Provider business mailing address

522 ALABAMA ST
COLUMBUS MS
39702-5306
US

V. Phone/Fax

Practice location:
  • Phone: 662-327-7271
  • Fax: 662-327-7271
Mailing address:
  • Phone: 623-277-2716
  • Fax: 662-327-7271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number466
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. REAGAN L FORD SR.
Title or Position: OWNER
Credential: O.D.
Phone: 662-323-0571