=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144685439
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRANT EYE CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/31/2015
-----------------------------------------------------
Last Update Date | 12/31/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5219 HIGHWAY 51 N
-----------------------------------------------------
City | SENATOBIA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38668-1719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-612-6016
-----------------------------------------------------
Fax | 662-612-6031
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5219 HIGHWAY 51 N
-----------------------------------------------------
City | SENATOBIA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38668-1719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-612-6016
-----------------------------------------------------
Fax | 662-612-6031
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JARED ACKER GRANT
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 662-612-6016
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 923
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------