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General NPI Number Information
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NPI Number | 1770996407
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Entity Type | Organization
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Legal Business Name | DESOTO EYE AND EAR
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Dates
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Enumeration Date | 06/10/2014
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Last Update Date | 06/10/2014
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Provider Practice Location Address
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Address Line | 5699 GETWELL RD BLDG G2
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City | SOUTHAVEN
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State | MS
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Zip | 38672-7303
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Country | US
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Telephone | 662-510-2138
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Fax |
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Provider Business Mailing Address
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Address Line | 5699 GETWELL RD BLDG G2
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City | SOUTHAVEN
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State | MS
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Zip | 38672-7303
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Country | US
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Telephone | 662-510-2138
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Fax |
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Authorized Official
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Title or Position | AUDIOLOGIST
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Name | DR. STACY SANDERS
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Credential | AUD
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Telephone | 662-510-2138
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 231H00000X
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Taxonomy Name | Audiologist
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License Number |
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License Number State |
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