Healthcare Provider Details

I. General information

NPI: 1497828495
Provider Name (Legal Business Name): WALLS VISION CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 SUNSET DR
GRENADA MS
38901-4061
US

IV. Provider business mailing address

1655 SUNSET DR
GRENADA MS
38901-4061
US

V. Phone/Fax

Practice location:
  • Phone: 662-226-0042
  • Fax: 662-226-4696
Mailing address:
  • Phone: 662-226-0042
  • Fax: 662-226-4696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number629
License Number StateMS

VIII. Authorized Official

Name: DR. CHRISTOPHER THOMAS WALLS
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 662-226-0042