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Eye and Vision Services Providers Optometrist

Provider NPI: 1932113404

Provider Information:
Gender: M
Sole Proprietor

Practice Location:
1620 HIGHWAY 15 N SUITE A-1 LAUREL, MS 39440-1892 US
Tel: 601-649-4106  Fax: --

Business Mailing Address:
1620 HIGHWAY 15 N SUITE A-1 LAUREL, MS 39440-1892 US
Tel: --  Fax: --

NPI Information:
NPI: 1932113404
Entity Type: Individual


PrimaryCodeCategory/DescriptionStateLicense Number
Y152W00000XEye and Vision Services Providers

Other Provider Identifiers:


American Medical Association 2012 taxonomy code information

Code: 152W00000X





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