Healthcare Provider Details

I. General information

NPI: 1144388539
Provider Name (Legal Business Name): OBREINEYECARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

354 STATELINE RD W
SOUTHAVEN MS
38671-1610
US

IV. Provider business mailing address

354 STATELINE RD W
SOUTHAVEN MS
38671-1610
US

V. Phone/Fax

Practice location:
  • Phone: 662-647-8707
  • Fax: 662-647-8706
Mailing address:
  • Phone: 662-647-8707
  • Fax: 662-647-8706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number426
License Number StateMS

VIII. Authorized Official

Name: DR. DAVID V OBRIEN
Title or Position: OWNER
Credential: OD
Phone: 662-647-8707