Healthcare Provider Details

I. General information

NPI: 1245480482
Provider Name (Legal Business Name): COLEMAN CATARACT AND EYE LASER SURGERY CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2008
Last Update Date: 09/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 HWY 82 W
GREENWOOD MS
38930
US

IV. Provider business mailing address

2005 HWY 82 W
GREENWOOD MS
38930
US

V. Phone/Fax

Practice location:
  • Phone: 662-455-4523
  • Fax: 662-455-3790
Mailing address:
  • Phone: 662-455-4523
  • Fax: 662-455-3790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberR792327
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMY BUSH
Title or Position: RN/ADMINISTRATOR
Credential:
Phone: 662-455-4523