Provider Demographics
NPI:1548575848
Name:EDGEWATER EYECARE, INC
Entity Type:Organization
Organization Name:EDGEWATER EYECARE, INC
Other - Org Name:VISION CARE CENTER/ OCEAN SPRINGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:K
Authorized Official - Last Name:RAINS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:228-875-8785
Mailing Address - Street 1:1626 BIENVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3000
Mailing Address - Country:US
Mailing Address - Phone:228-875-8785
Mailing Address - Fax:228-875-8745
Practice Address - Street 1:1626 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3000
Practice Address - Country:US
Practice Address - Phone:228-875-8785
Practice Address - Fax:228-875-8745
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDGEWATER EYECARE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS567152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087012Medicaid
MS00087012Medicaid