Healthcare Provider Details

I. General information

NPI: 1841357704
Provider Name (Legal Business Name): JACKSON EYE INSTITUTE AMBULATORY SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 12/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 LAKELAND DR SUITE B
JACKSON MS
39232-7641
US

IV. Provider business mailing address

2500 LAKELAND DR SUITE B
JACKSON MS
39232-7641
US

V. Phone/Fax

Practice location:
  • Phone: 601-939-0079
  • Fax: 601-939-6823
Mailing address:
  • Phone: 601-939-0079
  • Fax: 601-939-6823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number25C0001016
License Number StateMS

VIII. Authorized Official

Name: DR. JAMES ALVIN BRUCE JR.
Title or Position: OWNER
Credential: MD
Phone: 601-939-0079