Provider Demographics
NPI:1578730800
Name:INDIANOLA EYE CLINIC PA
Entity Type:Organization
Organization Name:INDIANOLA EYE CLINIC PA
Other - Org Name:DELTA EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILBURN
Authorized Official - Middle Name:
Authorized Official - Last Name:LORD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:662-332-0163
Mailing Address - Street 1:239 S. WASHINGTON AVE.
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38704
Mailing Address - Country:US
Mailing Address - Phone:662-332-0163
Mailing Address - Fax:662-378-3394
Practice Address - Street 1:224 VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:MS
Practice Address - Zip Code:38751-2221
Practice Address - Country:US
Practice Address - Phone:662-887-3671
Practice Address - Fax:662-887-3675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS460152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty