Provider Demographics
NPI:1215014022
Name:HATTIESBURG EYE CLINIC CATARACT & LASIK SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:HATTIESBURG EYE CLINIC CATARACT & LASIK SURGERY CENTER, LLC
Other - Org Name:HATTIESBURG EYE CLINIC CATARACT & LASIK SURGERY CENTER, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-268-5910
Mailing Address - Street 1:103 MILLSAPS DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1348
Mailing Address - Country:US
Mailing Address - Phone:601-268-9959
Mailing Address - Fax:601-268-9947
Practice Address - Street 1:103 MILLSAPS DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1348
Practice Address - Country:US
Practice Address - Phone:601-268-9959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03922537Medicaid
MS7299623OtherAETNA
MS490000054Medicare PIN
MS7299623OtherAETNA