=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780046540
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYEOLOGY EYECARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2016
-----------------------------------------------------
Last Update Date | 03/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 131 HANDLEY BLVD
-----------------------------------------------------
City | BYRAM
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39272-8983
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-346-7549
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 131 HANDLEY BLVD
-----------------------------------------------------
City | BYRAM
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39272-8983
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-346-7549
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DEANDRE MONIQUE CARR
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 601-346-7549
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 841
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------