Healthcare Provider Details

I. General information

NPI: 1114223823
Provider Name (Legal Business Name): COAST EYES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2011
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3887 PROMENADE PKWY SUITE C
D'IBERVILLE MS
39540-5379
US

IV. Provider business mailing address

3887 PROMENADE PKWY SUITE C
D'IBERVILLE MS
39540-5379
US

V. Phone/Fax

Practice location:
  • Phone: 228-392-8141
  • Fax: 228-392-8181
Mailing address:
  • Phone: 228-392-8141
  • Fax: 228-392-8181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number755
License Number StateMS

VIII. Authorized Official

Name: DR. SCOTT SANDERS
Title or Position: SOLE MEMBER
Credential: O.D.
Phone: 228-392-8141