Healthcare Provider Details

I. General information

NPI: 1093899023
Provider Name (Legal Business Name): MEDICAL MALL VISION CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 601-366-9020
  • Fax: 601-321-3979
Mailing address:
  • Phone: 601-366-9020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. W BOYCE CRAIG
Title or Position: OWNER
Credential:
Phone: 601-957-5252