Provider Demographics
NPI:1497830020
Name:PROFESSIONAL EYECARE ASSOCIATES ,INC
Entity Type:Organization
Organization Name:PROFESSIONAL EYECARE ASSOCIATES ,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:601-957-9292
Mailing Address - Street 1:6704 OLD CANTON RD
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1225
Mailing Address - Country:US
Mailing Address - Phone:601-957-9292
Mailing Address - Fax:601-957-7585
Practice Address - Street 1:6704 OLD CANTON RD
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-1225
Practice Address - Country:US
Practice Address - Phone:601-957-9292
Practice Address - Fax:601-957-7585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2014-09-16
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
MS03950565Medicaid