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General NPI Number Information
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NPI Number | 1467622605
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Entity Type | Organization
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Legal Business Name | CUSTOM OPTICAL OF FONDREN LLC
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Dates
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Enumeration Date | 03/04/2008
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Last Update Date | 04/29/2022
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Provider Practice Location Address
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Address Line | 661 DULING AVE
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City | JACKSON
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State | MS
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Zip | 39216-4008
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Country | US
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Telephone | 601-362-6675
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Fax | 601-362-5767
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Provider Business Mailing Address
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Address Line | 661 DULING AVE
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City | JACKSON
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State | MS
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Zip | 39216-4008
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Country | US
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Telephone | 601-362-6675
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Fax | 601-362-5767
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Authorized Official
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Title or Position | OWNER/OPTICIAN
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Name | PATRICIA HAMMONS
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Credential |
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Telephone | 601-362-6675
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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