Provider Demographics
NPI:1104045665
Name:ADVANCED EYECARE, LLC
Entity Type:Organization
Organization Name:ADVANCED EYECARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KRAIG
Authorized Official - Middle Name:MICHEAL
Authorized Official - Last Name:STASNEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:601-799-0707
Mailing Address - Street 1:5 ALEX PL
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-9697
Mailing Address - Country:US
Mailing Address - Phone:601-799-0707
Mailing Address - Fax:601-799-0700
Practice Address - Street 1:5 ALEX PL
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-9697
Practice Address - Country:US
Practice Address - Phone:601-799-0707
Practice Address - Fax:601-799-0700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS611152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05152521Medicaid
MSU59479Medicare UPIN
MSC03439Medicare PIN