Provider Demographics
NPI:1902957483
Name:EYE AND AESTHETIC SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:EYE AND AESTHETIC SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DELL
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHOATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-684-3112
Mailing Address - Street 1:414B MARION AVE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-2710
Mailing Address - Country:US
Mailing Address - Phone:601-684-9675
Mailing Address - Fax:601-684-9919
Practice Address - Street 1:414B MARION AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2710
Practice Address - Country:US
Practice Address - Phone:601-684-9675
Practice Address - Fax:601-684-9919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-13
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25C0001019261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770292Medicaid
MS00770292Medicaid
MS=========OtherBLUE CROSS BLUE SHIELD OF MS
MS490000011Medicare PIN