Provider Demographics
NPI:1245403351
Name:EYEDEAL OPTICAL YAZOO CITY LLC
Entity Type:Organization
Organization Name:EYEDEAL OPTICAL YAZOO CITY LLC
Other - Org Name:EYEDEAL OPTICAL YAZOO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:CPOA
Authorized Official - Phone:662-332-3325
Mailing Address - Street 1:2119 HIGHWAY 82 E
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-6010
Mailing Address - Country:US
Mailing Address - Phone:662-332-3325
Mailing Address - Fax:662-378-3325
Practice Address - Street 1:728 EAST 15TH STREET
Practice Address - Street 2:
Practice Address - City:YAZOO CITY
Practice Address - State:MS
Practice Address - Zip Code:39194
Practice Address - Country:US
Practice Address - Phone:662-332-3325
Practice Address - Fax:662-378-3325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty