Provider Demographics
NPI:1003098898
Name:KEBERT EYE CLINIC PLLC
Entity Type:Organization
Organization Name:KEBERT EYE CLINIC PLLC
Other - Org Name:KEBERT OPTICAL DISPENSARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:L
Authorized Official - Last Name:KEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-684-8118
Mailing Address - Street 1:1307 ASTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648
Mailing Address - Country:US
Mailing Address - Phone:601-684-8118
Mailing Address - Fax:601-249-0846
Practice Address - Street 1:1307 ASTON AVENUE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648
Practice Address - Country:US
Practice Address - Phone:601-684-8118
Practice Address - Fax:601-249-0846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880090Medicaid
MS4337220001Medicare NSC