Provider Demographics
NPI:1902156987
Name:CASS L. CLEMENTS, O.D., LLC
Entity Type:Organization
Organization Name:CASS L. CLEMENTS, O.D., LLC
Other - Org Name:FAMILY EYE CARE OF RIDGELAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CASS
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLEMENTS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:601-956-6557
Mailing Address - Street 1:1200 E COUNTY LINE RD
Mailing Address - Street 2:STE 164
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1904
Mailing Address - Country:US
Mailing Address - Phone:601-956-6557
Mailing Address - Fax:601-956-6559
Practice Address - Street 1:1200 E COUNTY LINE RD
Practice Address - Street 2:STE 164
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-1904
Practice Address - Country:US
Practice Address - Phone:601-956-6557
Practice Address - Fax:601-956-6559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS641152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880188Medicaid
MSU77113Medicaid
MS410000277Medicare PIN