1225301203 NPI number — OPTICAL ZONE, LLC

Table of content: TERRY ELAN CIRRENCIONE II (NPI 1366292633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225301203 NPI number — OPTICAL ZONE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTICAL ZONE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225301203
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2530 BERT KOUNS INDUSTRIAL LOOP
Provider Second Line Business Mailing Address:
SUITE 116
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71118-3132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-629-1870
Provider Business Mailing Address Fax Number:
318-629-1874

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2530 BERT KOUNS INDUSTRIAL LOOP
Provider Second Line Business Practice Location Address:
SUITE 116
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71118-3132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-629-1870
Provider Business Practice Location Address Fax Number:
318-629-1874
Provider Enumeration Date:
02/21/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SWEARINGEN
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
318-629-1870

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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