1952428005 NPI number — ST. CHARLES VISION OUTLET MANDEVILLE, LLC

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 1952428005 NPI number — ST. CHARLES VISION OUTLET MANDEVILLE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. CHARLES VISION OUTLET MANDEVILLE, 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:
1952428005
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1844 N. CAUSEWAY BLVD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANDEVILLE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70471
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-626-8103
Provider Business Mailing Address Fax Number:
985-626-5571

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1844 N. CAUSEWAY BLVD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANDEVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-626-8103
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROUSSEL
Authorized Official First Name:
KRISTY
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
985-626-8103

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1318453T , 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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