Provider Demographics
NPI:1932440138
Name:CHARLESTON VISION CENTER PA
Entity Type:Organization
Organization Name:CHARLESTON VISION CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEIGH
Authorized Official - Middle Name:
Authorized Official - Last Name:TACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-647-8707
Mailing Address - Street 1:1890 GOODMAN RD E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:288 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:MS
Practice Address - Zip Code:38921-2229
Practice Address - Country:US
Practice Address - Phone:662-647-8707
Practice Address - Fax:662-647-8706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-13
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS722152W00000X
MS152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty