Healthcare Provider Details

I. General information

NPI: 1366697799
Provider Name (Legal Business Name): MISSISSIPPI EYE CARE ASSOCIATES OF JACKSON, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2008
Last Update Date: 12/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 WEST WOODROW WILSON AVENUE SUITE 300
JACKSON MS
39213-7662
US

IV. Provider business mailing address

310 WEST WOODROW WILSON DRIVE SUITE 300
JACKSON MS
39213-7662
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. CHRISTOPHER TERRELL BULLIN
Title or Position: OWNER
Credential: O.D.
Phone: 601-366-9020