Provider Demographics
NPI:1013062298
Name:MBC INC
Entity Type:Organization
Organization Name:MBC INC
Other - Org Name:PERSELL EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:ONEAL
Authorized Official - Last Name:PERSELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:901-466-1333
Mailing Address - Street 1:7085 HIGHWAY 64
Mailing Address - Street 2:SUITE 2
Mailing Address - City:OAKLAND
Mailing Address - State:TN
Mailing Address - Zip Code:38060-3366
Mailing Address - Country:US
Mailing Address - Phone:901-466-1333
Mailing Address - Fax:901-466-1333
Practice Address - Street 1:7085 HIGHWAY 64
Practice Address - Street 2:SUITE 2
Practice Address - City:OAKLAND
Practice Address - State:TN
Practice Address - Zip Code:38060-3366
Practice Address - Country:US
Practice Address - Phone:901-466-1333
Practice Address - Fax:901-466-1333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2443152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4126391OtherBLUE CROSS BLUE SHIELD
TN4126391Medicaid