=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659546802
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PICAYUNE EYE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2008
-----------------------------------------------------
Last Update Date | 07/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1249 S MAIN ST
-----------------------------------------------------
City | POPLARVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39470-3313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-795-0137
-----------------------------------------------------
Fax | 601-798-4770
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 908 SIXTH AVE
-----------------------------------------------------
City | PICAYUNE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-798-4182
-----------------------------------------------------
Fax | 601-798-4770
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LORI L BLACKMER
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 601-798-4182
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 584
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 559
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------