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General NPI Number Information
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NPI Number | 1346501442
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Entity Type | Organization
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Legal Business Name | MUDDY WATER ENTERPRISES, LLC
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Dates
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Enumeration Date | 06/05/2012
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Last Update Date | 06/05/2012
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Provider Practice Location Address
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Address Line | 706 HIGHWAY 12 W STE F
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City | STARKVILLE
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State | MS
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Zip | 39759-3573
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Country | US
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Telephone | 662-323-0571
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Fax | 662-323-6365
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Provider Business Mailing Address
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Address Line | 706 HIGHWAY 12 W STE F
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City | STARKVILLE
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State | MS
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Zip | 39759-3573
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Country | US
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Telephone | 662-323-0571
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Fax | 662-323-6365
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Authorized Official
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Title or Position | MANAGER
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Name | DR. REAGAN LEE FORD II
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Credential | O.D.
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Telephone | 662-822-2020
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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 | 651
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License Number State | MS
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