Provider Demographics
NPI:1598884975
Name:DAN WINDHAM OPTICAL, INC.
Entity Type:Organization
Organization Name:DAN WINDHAM OPTICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:WINDHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-939-1981
Mailing Address - Street 1:2630 HWY 80 EAST
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208
Mailing Address - Country:US
Mailing Address - Phone:601-939-1981
Mailing Address - Fax:601-939-3357
Practice Address - Street 1:2630 HWY 80 EAST
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208
Practice Address - Country:US
Practice Address - Phone:601-939-1981
Practice Address - Fax:601-939-1981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS061087102332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0707980002Medicare NSC