Provider Demographics
NPI:1407029465
Name:SOUTHERN EYECARE, P.C.
Entity Type:Organization
Organization Name:SOUTHERN EYECARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:912-375-2516
Mailing Address - Street 1:P O BOX 430
Mailing Address - Street 2:25 CROSS ST
Mailing Address - City:HAZLEHURST
Mailing Address - State:GA
Mailing Address - Zip Code:31539-0430
Mailing Address - Country:US
Mailing Address - Phone:912-375-2516
Mailing Address - Fax:912-379-0755
Practice Address - Street 1:25 CROSS ST
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:GA
Practice Address - Zip Code:31539-6427
Practice Address - Country:US
Practice Address - Phone:912-375-2516
Practice Address - Fax:912-379-0755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001506152W00000X
GAOPT002403152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4795340001Medicare NSC