Healthcare Provider Details

I. General information

NPI: 1871602862
Provider Name (Legal Business Name): THE VISION CLINIC OF VICKSBURG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 MISSION 66
VICKSBURG MS
39180-3710
US

IV. Provider business mailing address

1808 MISSION 66
VICKSBURG MS
39180-3710
US

V. Phone/Fax

Practice location:
  • Phone: 601-636-6364
  • Fax: 601-636-1162
Mailing address:
  • Phone: 601-636-6364
  • Fax: 601-636-1162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number487
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number487
License Number StateMS

VIII. Authorized Official

Name: DR. WILLIAM SAMUEL ASHLEY
Title or Position: OWNER/PRESIDENT
Credential: O.D.
Phone: 601-636-6364