Provider Demographics
NPI:1497828495
Name:WALLS VISION CENTER LLC
Entity Type:Organization
Organization Name:WALLS VISION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WALLS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:662-226-0042
Mailing Address - Street 1:1655 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-4061
Mailing Address - Country:US
Mailing Address - Phone:662-226-0042
Mailing Address - Fax:662-226-4696
Practice Address - Street 1:1655 SUNSET DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4061
Practice Address - Country:US
Practice Address - Phone:662-226-0042
Practice Address - Fax:662-226-4696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS629152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02473861Medicaid
MS02473861Medicaid
MS=========OtherTAX ID NUMBER