Provider Demographics
NPI:1114902251
Name:ST. CHARLES VISION OUTLET ELMWOOD, LLC
Entity Type:Organization
Organization Name:ST. CHARLES VISION OUTLET ELMWOOD, LLC
Other - Org Name:ST. CHARLES VISION ELMWOOD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:DUPLESSIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-247-9116
Mailing Address - Street 1:837 S CLEARVIEW PKWY
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:LA
Mailing Address - Zip Code:70121-3119
Mailing Address - Country:US
Mailing Address - Phone:504-733-0406
Mailing Address - Fax:504-733-0801
Practice Address - Street 1:837 S CLEARVIEW PKWY
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:LA
Practice Address - Zip Code:70121-3119
Practice Address - Country:US
Practice Address - Phone:504-733-0406
Practice Address - Fax:504-733-0801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1079242T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA410026332OtherMEDICARE RAILROAD
LA410026332OtherMEDICARE RAILROAD
LA5D679Medicare PIN