1023152683 NPI number — ERIC THAI OD, LLC

Table of content: (NPI 1023152683)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023152683 NPI number — ERIC THAI OD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ERIC THAI OD, 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:
1023152683
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11331 OLD HAMMOND HWY
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70816-8461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-246-8830
Provider Business Mailing Address Fax Number:
225-248-6097

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11331 OLD HAMMOND HWY
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70816-8461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-246-8830
Provider Business Practice Location Address Fax Number:
225-248-6097
Provider Enumeration Date:
02/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
THAI
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
NHAN
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
225-246-8830

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1416-549T , 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)

  • Identifier: 1741051 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5CX17 . This is a "PTAN" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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