Provider Demographics
NPI:1275707226
Name:WILBURN LORD JR
Entity Type:Organization
Organization Name:WILBURN LORD JR
Other - Org Name:EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-332-0163
Mailing Address - Street 1:239 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-4234
Mailing Address - Country:US
Mailing Address - Phone:662-332-0163
Mailing Address - Fax:662-378-3394
Practice Address - Street 1:239 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-4234
Practice Address - Country:US
Practice Address - Phone:662-332-0163
Practice Address - Fax:662-378-3394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-21
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087850Medicaid
MSC02284Medicare PIN
MS410000156Medicare PIN