Provider Demographics
NPI:1922067016
Name:PICAYUNE EYE CLINIC
Entity Type:Organization
Organization Name:PICAYUNE EYE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLACKMER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:601-798-4182
Mailing Address - Street 1:908 SIXTH AVE
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-3802
Mailing Address - Country:US
Mailing Address - Phone:601-798-4182
Mailing Address - Fax:601-798-4770
Practice Address - Street 1:908 SIXTH AVE
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3802
Practice Address - Country:US
Practice Address - Phone:601-798-4182
Practice Address - Fax:601-798-4770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-20
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS559152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087010Medicaid
MS263673909OtherBLUE CROSS BLUE SHIELD
MSDA2690OtherMEDICARE/RR GROUP
0661580001OtherPALMETTOGBA
MS2230045OtherUNITED HEALTH CARE
MS410012249OtherMEDICARE RAILROAD RETIREM
MSC02306OtherMEDICARE GROUP
MSC02306OtherMEDICARE GROUP
MS263673909OtherBLUE CROSS BLUE SHIELD
MS410000163Medicare ID - Type Unspecified