Provider Demographics
NPI:1831307727
Name:EYELINE OPTICAL OF VICKSBURG, INC.
Entity Type:Organization
Organization Name:EYELINE OPTICAL OF VICKSBURG, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:MONSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-638-7905
Mailing Address - Street 1:2449 N FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5177
Mailing Address - Country:US
Mailing Address - Phone:601-638-7905
Mailing Address - Fax:
Practice Address - Street 1:2449 N FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5177
Practice Address - Country:US
Practice Address - Phone:601-638-7905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00089002Medicaid
MS0285030001Medicare ID - Type Unspecified