Healthcare Provider Details

I. General information

NPI: 1710177688
Provider Name (Legal Business Name): WILEY VISION CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2007
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MARKET PLACE DR
RICHLAND MS
39218
US

IV. Provider business mailing address

PO BOX 180369
RICHLAND MS
39218-0369
US

V. Phone/Fax

Practice location:
  • Phone: 601-420-2101
  • Fax:
Mailing address:
  • Phone: 601-397-0095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number721
License Number StateMS

VIII. Authorized Official

Name: DR. MARK EUGENE WILEY
Title or Position: MEMBER
Credential: O.D.
Phone: 601-420-2101