Provider Demographics
NPI:1184742843
Name:MENDENHALL OPTOMETRIC EYE CLINIC, P.A.
Entity type:Organization
Organization Name:MENDENHALL OPTOMETRIC EYE CLINIC, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:WILLARD
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:601-847-1232
Mailing Address - Street 1:P. O. BOX 577
Mailing Address - Street 2:
Mailing Address - City:MENDENHALL
Mailing Address - State:MS
Mailing Address - Zip Code:39114-3107
Mailing Address - Country:US
Mailing Address - Phone:601-847-1232
Mailing Address - Fax:601-847-1376
Practice Address - Street 1:1021 EAST ST
Practice Address - Street 2:
Practice Address - City:MENDENHALL
Practice Address - State:MS
Practice Address - Zip Code:39114-3107
Practice Address - Country:US
Practice Address - Phone:601-847-1232
Practice Address - Fax:601-847-1376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS423152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC03245OtherGROUP SUPPLIER CODE
MS00087015Medicaid
MS=========OtherTAX ID
MST20982Medicare UPIN
MSC03245OtherGROUP SUPPLIER CODE