Provider Demographics
NPI:1952703209
Name:RESERVOIR EYE CARE CLINIC PLLC
Entity Type:Organization
Organization Name:RESERVOIR EYE CARE CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMENTS-MATNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-613-8403
Mailing Address - Street 1:PO BOX 2887
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-2887
Mailing Address - Country:US
Mailing Address - Phone:601-613-8403
Mailing Address - Fax:
Practice Address - Street 1:536 LINDLEY RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-2301
Practice Address - Country:US
Practice Address - Phone:601-613-8403
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS641152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty