Healthcare Provider Details

I. General information

NPI: 1497025183
Provider Name (Legal Business Name): 20-20 EYECARE OF GRENADA PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 OLD HICKORY RD
GRENADA MS
38901-2727
US

IV. Provider business mailing address

600 OLD HICKORY RD
GRENADA MS
38901-2727
US

V. Phone/Fax

Practice location:
  • Phone: 662-226-7010
  • Fax: 662-226-7027
Mailing address:
  • Phone: 662-226-7010
  • Fax: 662-226-7027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. CHRISTOPHER T WALLS
Title or Position: OWNER
Credential: OD
Phone: 662-226-7010