Provider Demographics
NPI:1841357704
Name:JACKSON EYE INSTITUTE AMBULATORY SURGERY CENTER LLC
Entity type:Organization
Organization Name:JACKSON EYE INSTITUTE AMBULATORY SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ALVIN
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:601-939-0079
Mailing Address - Street 1:2500 LAKELAND DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39232-7641
Mailing Address - Country:US
Mailing Address - Phone:601-939-0079
Mailing Address - Fax:601-939-6823
Practice Address - Street 1:2500 LAKELAND DR
Practice Address - Street 2:SUITE B
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39232-7641
Practice Address - Country:US
Practice Address - Phone:601-939-0079
Practice Address - Fax:601-939-6823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25C0001016261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770208Medicaid
MSB30785Medicare UPIN
MS490000008Medicare ID - Type Unspecified