Healthcare Provider Details

I. General information

NPI: 1811957624
Provider Name (Legal Business Name): RIVERBEND EYECARE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 PEMBERTON SQUARE BLVD SUITE 45
VICKSBURG MS
39180-5537
US

IV. Provider business mailing address

3505 PEMBERTON SQUARE BLVD SUITE 45
VICKSBURG MS
39180-5537
US

V. Phone/Fax

Practice location:
  • Phone: 601-630-9199
  • Fax: 601-630-0426
Mailing address:
  • Phone: 601-630-9199
  • Fax: 601-630-0426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberMS579
License Number StateMS

VIII. Authorized Official

Name: DR. DAVID L. PRUDHOMME
Title or Position: PRESIDENT
Credential: O.D.
Phone: 601-630-9199