1942487087 NPI number — DR ELVIS SURLES A PROFESSIONAL OPTOMETRY CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942487087 NPI number — DR ELVIS SURLES A PROFESSIONAL OPTOMETRY CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR ELVIS SURLES A PROFESSIONAL OPTOMETRY CORPORATION
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:
SURLES OPTICAL
Provider Other Organization Name Type Code:
5
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:
1942487087
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2209 FORSYTHE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71201-3643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-387-5657
Provider Business Mailing Address Fax Number:
318-325-8472

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2209 FORSYTHE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71201-3643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-387-5657
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LORD
Authorized Official First Name:
MARY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
318-387-5657

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  19643 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 717127T , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1946192 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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