Healthcare Provider Details

I. General information

NPI: 1013130988
Provider Name (Legal Business Name): ROLLING FORK EYE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 S FOURTH ST
ROLLING FORK MS
39159-5147
US

IV. Provider business mailing address

PO BOX 185
ROLLING FORK MS
39159-0185
US

V. Phone/Fax

Practice location:
  • Phone: 662-873-4045
  • Fax: 662-873-4452
Mailing address:
  • Phone: 662-873-4045
  • Fax: 662-873-4452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MS. RUTH C ANDERSON
Title or Position: PRACTICE MANAGER
Credential:
Phone: 662-332-0163