MEDICARE: TALLAHATCHIE EYECARE, PLLC

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	793	MS

General Provider Information

NPI Number	:	1164670329
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TALLAHATCHIE EYECARE, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 200
Second Line	:
City	:	CHARLESTON
State	:	MS
Zip	:	38921-0200
Country	:	US
Telephone Number	:	662-647-3500
Fax Number	:

Provider Business Practice Location Address
First Line	:	203 S MARKET ST
Second Line	:
City	:	CHARLESTON
State	:	MS
Zip	:	38921-2236
Country	:	US
Telephone Number	:	662-647-3500
Fax Number	:

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	LANA DEE LEWIS
Credential	:	O.D.
Telephone Number	:	662-647-3500

Provider Enumeration Date	:	08/29/2008
Last Update Date	:	08/29/2008

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