Provider Demographics
NPI:1326394677
Name:TAYLORSVILLE EYE CARE LLC
Entity Type:Organization
Organization Name:TAYLORSVILLE EYE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-785-0111
Mailing Address - Street 1:PO BOX 1280
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39168-1280
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 PINE ST
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:MS
Practice Address - Zip Code:39168-5432
Practice Address - Country:US
Practice Address - Phone:601-785-0111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-24
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07927516Medicaid
MS07927516Medicaid
MS6712510001Medicare NSC