Provider Demographics
NPI:1831140300
Name:MOTHERSHED OPTOMETRY ASSOCIATES P.L.L.C.
Entity Type:Organization
Organization Name:MOTHERSHED OPTOMETRY ASSOCIATES P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SONDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-844-3555
Mailing Address - Street 1:3353 N GLOSTER ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-9735
Mailing Address - Country:US
Mailing Address - Phone:662-844-3555
Mailing Address - Fax:662-840-5614
Practice Address - Street 1:3353 N GLOSTER ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-9735
Practice Address - Country:US
Practice Address - Phone:662-844-3555
Practice Address - Fax:662-840-5614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016215Medicaid
MS4594880001Medicare NSC
MSC03047Medicare PIN