Provider Demographics
NPI:1467622605
Name:CUSTOM OPTICAL OF FONDREN LLC
Entity Type:Organization
Organization Name:CUSTOM OPTICAL OF FONDREN LLC
Other - Org Name:CUSTOM OPTICAL OF FONDREN LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-362-6675
Mailing Address - Street 1:661 DULING AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4008
Mailing Address - Country:US
Mailing Address - Phone:601-362-6675
Mailing Address - Fax:601-362-5767
Practice Address - Street 1:661 DULING AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4008
Practice Address - Country:US
Practice Address - Phone:601-362-6675
Practice Address - Fax:601-362-5767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS5640700001Medicare NSC