Provider Demographics
NPI:1578575064
Name:MULLIS EYE INSTITUTE INC
Entity Type:Organization
Organization Name:MULLIS EYE INSTITUTE INC
Other - Org Name:AMBULATORY SURGICAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-763-6666
Mailing Address - Street 1:1600 JENKS AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4644
Mailing Address - Country:US
Mailing Address - Phone:850-763-6666
Mailing Address - Fax:850-763-6665
Practice Address - Street 1:1600 JENKS AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4644
Practice Address - Country:US
Practice Address - Phone:850-763-6666
Practice Address - Fax:850-763-6665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL948261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL062935900Medicaid
GA490002550Medicare PIN
FLF1022Medicare PIN