Healthcare Provider Details

I. General information

NPI: 1245505825
Provider Name (Legal Business Name): MISSISSIPPI EYE CARE OF HAZLEHURST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2012
Last Update Date: 03/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28063 HIGHWAY 28
HAZLEHURST MS
39083-2240
US

IV. Provider business mailing address

350 W WOODROW WILSON AVE SUITE 3110
JACKSON MS
39213-7681
US

V. Phone/Fax

Practice location:
  • Phone: 601-212-7411
  • Fax:
Mailing address:
  • Phone: 601-212-7411
  • Fax: 601-321-3979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number783
License Number StateMS

VIII. Authorized Official

Name: DR. CHRISTOPHER BULLIN
Title or Position: OWNER
Credential: O.D.
Phone: 601-212-7411