Provider Demographics
NPI:1881745941
Name:EYEDEAL OPTICAL CLEVELAND LLC
Entity type:Organization
Organization Name:EYEDEAL OPTICAL CLEVELAND LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REAGAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:FORD
Authorized Official - Suffix:II
Authorized Official - Credentials:OD
Authorized Official - Phone:662-332-3325
Mailing Address - Street 1:2119 HIGHWAY 82 E
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-6010
Mailing Address - Country:US
Mailing Address - Phone:662-332-3325
Mailing Address - Fax:662-378-3325
Practice Address - Street 1:425 N DAVIS AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2351
Practice Address - Country:US
Practice Address - Phone:662-843-8771
Practice Address - Fax:662-843-8750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS651152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty