Provider Demographics
NPI:1114129368
Name:CHEATHAM EYECARE LLC
Entity Type:Organization
Organization Name:CHEATHAM EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHEATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:662-494-5984
Mailing Address - Street 1:227 COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39773-2921
Mailing Address - Country:US
Mailing Address - Phone:662-494-5984
Mailing Address - Fax:662-494-3805
Practice Address - Street 1:227 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:MS
Practice Address - Zip Code:39773-2921
Practice Address - Country:US
Practice Address - Phone:662-494-5984
Practice Address - Fax:662-494-3805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS656332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016249Medicaid
MS426556546AOtherBLUE CROSS
MS4680740001Medicare NSC
MSU83328Medicare UPIN
MS09016249Medicaid