Provider Demographics
NPI:1689852055
Name:FORD VISION CLINIC
Entity Type:Organization
Organization Name:FORD VISION CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REAGAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:FORD
Authorized Official - Suffix:SR
Authorized Official - Credentials:OD
Authorized Official - Phone:662-323-0571
Mailing Address - Street 1:706F HIGHWAY 12 W
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-3573
Mailing Address - Country:US
Mailing Address - Phone:662-323-0571
Mailing Address - Fax:662-323-6365
Practice Address - Street 1:706F HIGHWAY 12 W
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-3573
Practice Address - Country:US
Practice Address - Phone:662-323-0571
Practice Address - Fax:662-323-6365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS466152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087840Medicaid
MS00087840Medicaid
MS5088110001Medicare NSC