Provider Demographics
NPI:1043645666
Name:ADVANCED EYECARE, LLC
Entity Type:Organization
Organization Name:ADVANCED EYECARE, LLC
Other - Org Name:GRANGER EYE STUDIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST, CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRANGER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:337-451-4511
Mailing Address - Street 1:107 CENTRE SARCELLE BLVD.
Mailing Address - Street 2:SUITE 704
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592
Mailing Address - Country:US
Mailing Address - Phone:337-451-4511
Mailing Address - Fax:337-857-6044
Practice Address - Street 1:107 CENTRE SARCELLE BLVD.
Practice Address - Street 2:SUITE 704
Practice Address - City:YOUNGSVILLE
Practice Address - State:LA
Practice Address - Zip Code:70592
Practice Address - Country:US
Practice Address - Phone:337-451-4511
Practice Address - Fax:337-857-6044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-13
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1611-644T261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2167626Medicaid
LA2167626Medicaid