Provider Demographics
NPI:1407010937
Name:HAZLEHURST EYE CLINIC, P.C.
Entity Type:Organization
Organization Name:HAZLEHURST EYE CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:P
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:601-894-2951
Mailing Address - Street 1:118 CALDWELL DR
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:MS
Mailing Address - Zip Code:39083-3023
Mailing Address - Country:US
Mailing Address - Phone:601-894-2951
Mailing Address - Fax:601-894-2952
Practice Address - Street 1:118 CALDWELL DR
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:MS
Practice Address - Zip Code:39083-3023
Practice Address - Country:US
Practice Address - Phone:601-894-2951
Practice Address - Fax:601-894-2952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-14
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS787152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01081512Medicaid