Healthcare Provider Details

I. General information

NPI: 1326304858
Provider Name (Legal Business Name): MISSISSIPPI EYE GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 03/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 GLUCKSTADT RD B
MADISON MS
39110
US

IV. Provider business mailing address

1040 GLUCKSTADT RD B
MADISON MS
39110
US

V. Phone/Fax

Practice location:
  • Phone: 601-853-1998
  • Fax: 601-853-1999
Mailing address:
  • Phone: 601-853-1998
  • Fax: 601-853-1999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. CHRISTOPHER EVAN COOK
Title or Position: OWNER/DOCTOR
Credential: OD.
Phone: 404-481-7931