Provider Demographics
NPI:1003952383
Name:COLDWATER VISION CENTER LLC
Entity Type:Organization
Organization Name:COLDWATER VISION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KRISTOPHER
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MAY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:662-622-5173
Mailing Address - Street 1:PO BOX 486
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MS
Mailing Address - Zip Code:38618-0486
Mailing Address - Country:US
Mailing Address - Phone:662-622-5173
Mailing Address - Fax:662-622-5590
Practice Address - Street 1:412 CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MS
Practice Address - Zip Code:38618
Practice Address - Country:US
Practice Address - Phone:662-622-5173
Practice Address - Fax:662-622-5590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08152004Medicaid
MS08152004Medicaid
MS5405940001Medicare NSC
=========OtherTIN FOR GROUP