=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306010897
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TINA SOREY DOCTOR OF OPTOMETRY, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2008
-----------------------------------------------------
Last Update Date | 04/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 117 LUCKNEY STATION
-----------------------------------------------------
City | FLOWOOD
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39232-8027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-992-7275
-----------------------------------------------------
Fax | 601-992-7244
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 117 LUCKNEY STATION
-----------------------------------------------------
City | FLOWOOD
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39232-8027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-992-7275
-----------------------------------------------------
Fax | 601-992-7244
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TINA RENEE SOREY
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 601-992-7275
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 637
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------