Provider Demographics
NPI:1073754602
Name:DESOTO EYE SURGERY CENTER LLC
Entity Type:Organization
Organization Name:DESOTO EYE SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:SCHAEFFER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-349-1959
Mailing Address - Street 1:726 GOODMAN RD E
Mailing Address - Street 2:SUITE B
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9530
Mailing Address - Country:US
Mailing Address - Phone:662-349-1959
Mailing Address - Fax:662-349-0424
Practice Address - Street 1:726 GOODMAN RD E
Practice Address - Street 2:SUITE B
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9530
Practice Address - Country:US
Practice Address - Phone:662-349-1959
Practice Address - Fax:662-349-0424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-11
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00959926OtherRAILROAD MEDICARE
MS302G496047Medicare PIN