=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245505825
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MISSISSIPPI EYE CARE OF HAZLEHURST
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2012
-----------------------------------------------------
Last Update Date | 03/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28063 HIGHWAY 28
-----------------------------------------------------
City | HAZLEHURST
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39083-2240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-212-7411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 W WOODROW WILSON AVE SUITE 3110
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39213-7681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-212-7411
-----------------------------------------------------
Fax | 601-321-3979
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CHRISTOPHER BULLIN
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 601-212-7411
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 783
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------