Provider Demographics
NPI:1215398631
Name:STONEWALL EYE CARE
Entity Type:Organization
Organization Name:STONEWALL EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALISA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:BROGDEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:318-780-5999
Mailing Address - Street 1:10904 DAUPHINE ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-8531
Mailing Address - Country:US
Mailing Address - Phone:318-780-5999
Mailing Address - Fax:
Practice Address - Street 1:2434 HIGHWAY 171
Practice Address - Street 2:
Practice Address - City:STONEWALL
Practice Address - State:LA
Practice Address - Zip Code:71078-9420
Practice Address - Country:US
Practice Address - Phone:318-780-5999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1533-563T261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty