Healthcare Provider Details

I. General information

NPI: 1013256411
Provider Name (Legal Business Name): MISSISSIPPI EYECARE ASSOCIATES OF PEARL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2013
Last Update Date: 08/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 RIVERWIND DR STE B1
PEARL MS
39208-5900
US

IV. Provider business mailing address

404 RIVERWIND DR STE B1
PEARL MS
39208-5900
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 TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number783
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number783
License Number StateMS

VIII. Authorized Official

Name: MS. AMANDA GUIDRY
Title or Position: OFFICE MANAGER
Credential:
Phone: 601-366-9020