Healthcare Provider Details

I. General information

NPI: 1184742843
Provider Name (Legal Business Name): MENDENHALL OPTOMETRIC EYE CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 EAST ST
MENDENHALL MS
39114-3107
US

IV. Provider business mailing address

P. O. BOX 577
MENDENHALL MS
39114-3107
US

V. Phone/Fax

Practice location:
  • Phone: 601-847-1232
  • Fax: 601-847-1376
Mailing address:
  • Phone: 601-847-1232
  • Fax: 601-847-1376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number423
License Number StateMS

VIII. Authorized Official

Name: PAUL WILLARD CLARK
Title or Position: PRESIDENT
Credential: O.D.
Phone: 601-847-1232