Provider Demographics
NPI:1235342056
Name:CLARKSDALE VISION CENTER PA
Entity Type:Organization
Organization Name:CLARKSDALE VISION CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:FLOWERS
Authorized Official - Last Name:HUMBER
Authorized Official - Suffix:IV
Authorized Official - Credentials:OD
Authorized Official - Phone:662-627-2020
Mailing Address - Street 1:636 FRIARS POINT RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-9111
Mailing Address - Country:US
Mailing Address - Phone:662-627-2020
Mailing Address - Fax:662-627-7063
Practice Address - Street 1:636 FRIARS POINT RD
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-9111
Practice Address - Country:US
Practice Address - Phone:662-627-2020
Practice Address - Fax:662-627-7063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS633152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880128Medicaid
MS410000188Medicare PIN
MSU73605Medicare UPIN
MS0129730001Medicare NSC