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General NPI Number Information
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NPI Number | 1922067016
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Entity Type | Organization
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Legal Business Name | PICAYUNE EYE CLINIC
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Dates
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Enumeration Date | 03/20/2006
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Last Update Date | 03/18/2010
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Provider Practice Location Address
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Address Line | 908 SIXTH AVE
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City | PICAYUNE
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State | MS
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Zip | 39466-3802
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Country | US
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Telephone | 601-798-4182
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Fax | 601-798-4770
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Provider Business Mailing Address
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Address Line | 908 SIXTH AVE
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City | PICAYUNE
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State | MS
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Zip | 39466-3802
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Country | US
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Telephone | 601-798-4182
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Fax | 601-798-4770
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Authorized Official
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Title or Position | OWNER
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Name | LORI L BLACKMER
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Credential | O.D.
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Telephone | 601-798-4182
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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 | 559
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License Number State | MS
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