Provider Demographics
NPI:1013130988
Name:ROLLING FORK EYE CLINIC
Entity Type:Organization
Organization Name:ROLLING FORK EYE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:C
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-332-0163
Mailing Address - Street 1:PO BOX 185
Mailing Address - Street 2:
Mailing Address - City:ROLLING FORK
Mailing Address - State:MS
Mailing Address - Zip Code:39159-0185
Mailing Address - Country:US
Mailing Address - Phone:662-873-4045
Mailing Address - Fax:662-873-4452
Practice Address - Street 1:64 S FOURTH ST
Practice Address - Street 2:
Practice Address - City:ROLLING FORK
Practice Address - State:MS
Practice Address - Zip Code:39159-5147
Practice Address - Country:US
Practice Address - Phone:662-873-4045
Practice Address - Fax:662-873-4452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087850Medicaid