MEDICARE: ENVISION EYE CARE, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	658	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083734867
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENVISION EYE CARE, INC

Provider Business Mailing Address
First Line	:	1316 NORTH STATE STREET
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39202
Country	:	US
Telephone Number	:	601-987-3937
Fax Number	:	601-987-3922

Provider Business Practice Location Address
First Line	:	1316 NORTH STATE STREET
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39202
Country	:	US
Telephone Number	:	601-987-3937
Fax Number	:	601-987-3922

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. TONYATTA T. HAIRSTON
Credential	:	O.D.
Telephone Number	:	601-987-3937

Provider Enumeration Date	:	03/29/2007
Last Update Date	:	07/08/2011

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Directions to “ENVISION EYE CARE, INC ” Practice Location

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