Provider Demographics
NPI:1528416641
Name:SOUTHERN EYE SURGERY AND LASER CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHERN EYE SURGERY AND LASER CENTER, LLC
Other - Org Name:SOUTHERN EYE CENTER - LAUREL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, LLC MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KIPER
Authorized Official - Middle Name:C
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-264-3937
Mailing Address - Street 1:1420 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3107
Mailing Address - Country:US
Mailing Address - Phone:601-705-0078
Mailing Address - Fax:
Practice Address - Street 1:1923 W 10TH ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-2538
Practice Address - Country:US
Practice Address - Phone:601-264-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery