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General NPI Number Information
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NPI Number | 1184742843
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Entity Type | Organization
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Legal Business Name | MENDENHALL OPTOMETRIC EYE CLINIC, P.A.
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Dates
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Enumeration Date | 03/27/2007
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | 1021 EAST ST
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City | MENDENHALL
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State | MS
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Zip | 39114-3107
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Country | US
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Telephone | 601-847-1232
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Fax | 601-847-1376
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Provider Business Mailing Address
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Address Line | P. O. BOX 577
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City | MENDENHALL
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State | MS
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Zip | 39114-3107
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Country | US
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Telephone | 601-847-1232
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Fax | 601-847-1376
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Authorized Official
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Title or Position | PRESIDENT
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Name | PAUL WILLARD CLARK
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Credential | O.D.
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Telephone | 601-847-1232
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 423
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License Number State | MS
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