Provider Demographics
NPI:1497025183
Name:20-20 EYECARE OF GRENADA PA
Entity Type:Organization
Organization Name:20-20 EYECARE OF GRENADA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:T
Authorized Official - Last Name:WALLS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:662-226-7010
Mailing Address - Street 1:600 OLD HICKORY RD
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-2727
Mailing Address - Country:US
Mailing Address - Phone:662-226-7010
Mailing Address - Fax:662-226-7027
Practice Address - Street 1:600 OLD HICKORY RD
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-2727
Practice Address - Country:US
Practice Address - Phone:662-226-7010
Practice Address - Fax:662-226-7027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-11
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880101Medicaid
MS00880101Medicaid