Provider Demographics
NPI:1144388539
Name:OBREINEYECARE
Entity Type:Organization
Organization Name:OBREINEYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:V
Authorized Official - Last Name:OBRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:662-647-8707
Mailing Address - Street 1:354 STATELINE RD W
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-1610
Mailing Address - Country:US
Mailing Address - Phone:662-647-8707
Mailing Address - Fax:662-647-8706
Practice Address - Street 1:354 STATELINE RD W
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1610
Practice Address - Country:US
Practice Address - Phone:662-647-8707
Practice Address - Fax:662-647-8706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS426152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087700Medicaid