MEDICARE: EYECARE SURGERY CENTER, LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center	14957	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	:	1821336371
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYECARE SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	1501 LAKELAND DR STE 101
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39216-4839
Country	:	US
Telephone Number	:	601-366-1085
Fax Number	:	601-366-5186

Provider Business Practice Location Address
First Line	:	1501 LAKELAND DR STE 101
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39216-4839
Country	:	US
Telephone Number	:	601-366-1085
Fax Number	:	601-366-5186

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KIRK R JEFFREYS III
Credential	:	M.D.
Telephone Number	:	601-366-1085

Provider Enumeration Date	:	01/17/2013
Last Update Date	:	01/17/2013

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