Provider Demographics
NPI:1083734867
Name:ENVISION EYE CARE, INC
Entity Type:Organization
Organization Name:ENVISION EYE CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONYATTA
Authorized Official - Middle Name:T
Authorized Official - Last Name:HAIRSTON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:601-987-3937
Mailing Address - Street 1:1316 NORTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202
Mailing Address - Country:US
Mailing Address - Phone:601-987-3937
Mailing Address - Fax:601-987-3922
Practice Address - Street 1:1316 NORTH STATE STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202
Practice Address - Country:US
Practice Address - Phone:601-987-3937
Practice Address - Fax:601-987-3922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS658152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05254312Medicaid
MS05254312Medicaid
MSC03140Medicare PIN