=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952703209
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESERVOIR EYE CARE CLINIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2014
-----------------------------------------------------
Last Update Date | 09/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 536 LINDLEY RD
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39305-2301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-613-8403
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2887
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39302-2887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-613-8403
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OD/OWNER
-----------------------------------------------------
Name | CASSANDRA CLEMENTS-MATNEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-613-8403
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 641
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------