Healthcare Provider Details

I. General information

NPI: 1922067016
Provider Name (Legal Business Name): PICAYUNE EYE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 03/18/2010
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: LORI L BLACKMER
Title or Position: OWNER
Credential: O.D.
Phone: 601-798-4182