Provider Demographics
NPI:1083266498
Name:MILES, ROYCE VANDIVER JR
Entity Type:Individual
Prefix:
First Name:ROYCE
Middle Name:VANDIVER
Last Name:MILES
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3027 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:MS
Mailing Address - Zip Code:39341-2275
Mailing Address - Country:US
Mailing Address - Phone:662-726-6111
Mailing Address - Fax:662-726-6110
Practice Address - Street 1:3027 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MS
Practice Address - Zip Code:39341-2275
Practice Address - Country:US
Practice Address - Phone:662-726-6111
Practice Address - Fax:662-726-6110
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS995152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist