Provider Demographics
NPI:1871602862
Name:THE VISION CLINIC OF VICKSBURG LLC
Entity type:Organization
Organization Name:THE VISION CLINIC OF VICKSBURG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:ASHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:601-636-6364
Mailing Address - Street 1:1808 MISSION 66
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3710
Mailing Address - Country:US
Mailing Address - Phone:601-636-6364
Mailing Address - Fax:601-636-1162
Practice Address - Street 1:1808 MISSION 66
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3710
Practice Address - Country:US
Practice Address - Phone:601-636-6364
Practice Address - Fax:601-636-1162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS487152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087909Medicaid
MST19414Medicare UPIN
MS00087909Medicaid
MS4940200001Medicare NSC