Provider Demographics
NPI:1205001005
Name:OPTICAL 2000 OF RICHLAND
Entity Type:Organization
Organization Name:OPTICAL 2000 OF RICHLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:C
Authorized Official - Last Name:PANKEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:601-932-3727
Mailing Address - Street 1:655 HIGHWAY 49 S
Mailing Address - Street 2:SUITE M
Mailing Address - City:RICHLAND
Mailing Address - State:MS
Mailing Address - Zip Code:39218-8419
Mailing Address - Country:US
Mailing Address - Phone:601-932-3727
Mailing Address - Fax:
Practice Address - Street 1:655 HIGHWAY 49 S
Practice Address - Street 2:SUITE M
Practice Address - City:RICHLAND
Practice Address - State:MS
Practice Address - Zip Code:39218-8419
Practice Address - Country:US
Practice Address - Phone:601-932-3727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00748152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014038Medicaid