Healthcare Provider Details

I. General information

NPI: 1336236710
Provider Name (Legal Business Name): THE EYE SURGERY AND LASER CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MARSHALL ST SUITE 604
JACKSON MS
39202-1651
US

IV. Provider business mailing address

501 MARSHALL ST SUITE 604
JACKSON MS
39202-1651
US

V. Phone/Fax

Practice location:
  • Phone: 601-985-9120
  • Fax: 601-985-9122
Mailing address:
  • Phone: 601-985-9120
  • Fax: 601-985-9122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number07279
License Number StateMS

VIII. Authorized Official

Name: DR. WILLIAM C ASHFORD
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 601-985-9120