Healthcare Provider Details

I. General information

NPI: 1760451595
Provider Name (Legal Business Name): LORI L BLACKMER O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 03/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 SIXTH AVE
PICAYUNE MS
39466-3802
US

IV. Provider business mailing address

908 SIXTH AVE
PICAYUNE MS
39466-3802
US

V. Phone/Fax

Practice location:
  • Phone: 601-798-4182
  • Fax: 601-798-4770
Mailing address:
  • Phone: 601-798-4182
  • Fax: 601-798-4770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number559
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: