Healthcare Provider Details

I. General information

NPI: 1083734867
Provider Name (Legal Business Name): ENVISION EYE CARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 NORTH STATE STREET
JACKSON MS
39202
US

IV. Provider business mailing address

1316 NORTH STATE STREET
JACKSON MS
39202
US

V. Phone/Fax

Practice location:
  • Phone: 601-987-3937
  • Fax: 601-987-3922
Mailing address:
  • Phone: 601-987-3937
  • Fax: 601-987-3922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number658
License Number StateMS

VIII. Authorized Official

Name: MRS. TONYATTA T. HAIRSTON
Title or Position: OWNER
Credential: O.D.
Phone: 601-987-3937