Healthcare Provider Details

I. General information

NPI: 1497783864
Provider Name (Legal Business Name): SALLYE S. SCOTT OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 S MAIN STREET
SARDIS MS
38666
US

IV. Provider business mailing address

PO BOX 385
SARDIS MS
38666-0385
US

V. Phone/Fax

Practice location:
  • Phone: 662-487-1316
  • Fax: 662-487-9270
Mailing address:
  • Phone: 662-487-1316
  • Fax: 662-487-9270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number472
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: