Healthcare Provider Details

I. General information

NPI: 1447794797
Provider Name (Legal Business Name): OPTICAL 2000 OF FLORA PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2016
Last Update Date: 03/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4843 MAIN ST.
FLORA MS
39071
US

IV. Provider business mailing address

115 CYNTHIA ST
CLINTON MS
39056-3711
US

V. Phone/Fax

Practice location:
  • Phone: 601-879-5550
  • Fax:
Mailing address:
  • Phone: 601-924-4444
  • Fax: 601-924-4100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number00748
License Number StateMS

VIII. Authorized Official

Name: BOBBY PANKEY
Title or Position: OPTOMETRIST
Credential: OD
Phone: 601-879-5550