Healthcare Provider Details

I. General information

NPI: 1316113616
Provider Name (Legal Business Name): COLLINS EYE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 MISSION 66
VICKSBURG MS
39183-3137
US

IV. Provider business mailing address

1206 MISSION 66
VICKSBURG MS
39183-3137
US

V. Phone/Fax

Practice location:
  • Phone: 601-638-2081
  • Fax: 601-638-2171
Mailing address:
  • Phone: 601-638-2081
  • Fax: 601-638-2171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number522
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number522
License Number StateMS

VIII. Authorized Official

Name: C. CHRIS COLLINS
Title or Position: PRESIDENT
Credential: OD
Phone: 601-638-2081