Healthcare Provider Details

I. General information

NPI: 1003055872
Provider Name (Legal Business Name): M H ALLEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2009
Last Update Date: 07/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4810 LAKELAND DR
FLOWOOD MS
39232-8694
US

IV. Provider business mailing address

PO BOX 321443
FLOWOOD MS
39232-1443
US

V. Phone/Fax

Practice location:
  • Phone: 601-939-6366
  • Fax: 601-939-3482
Mailing address:
  • Phone: 601-939-6366
  • Fax: 601-939-3482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number621
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number621
License Number StateMS

VIII. Authorized Official

Name: DR. MARK H ALLEN
Title or Position: OWNER/OPTOMETRIST
Credential: OD
Phone: 601-939-6366