Provider Demographics
NPI:1003019878
Name:OLIVE BRANCH EYECARE, PLLC
Entity Type:Organization
Organization Name:OLIVE BRANCH EYECARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:662-893-3300
Mailing Address - Street 1:6947 CRUMPLER BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-1922
Mailing Address - Country:US
Mailing Address - Phone:662-893-3300
Mailing Address - Fax:
Practice Address - Street 1:6947 CRUMPLER BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1922
Practice Address - Country:US
Practice Address - Phone:662-893-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09577062Medicaid
DG2594OtherRAILROAD MEDICARE PIN
DG2594OtherRAILROAD MEDICARE PIN
MSC03787Medicare PIN