Provider Demographics
NPI:1881810729
Name:EYEDEAL OPTICAL OUTLET INC.
Entity type:Organization
Organization Name:EYEDEAL OPTICAL OUTLET INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:B
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-320-6636
Mailing Address - Street 1:1085 STARK RD STE C
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-3682
Mailing Address - Country:US
Mailing Address - Phone:662-320-6636
Mailing Address - Fax:662-320-3838
Practice Address - Street 1:1085 STARK RD STE C
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-3682
Practice Address - Country:US
Practice Address - Phone:662-320-6636
Practice Address - Fax:662-320-3838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS767152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08487842Medicaid