Provider Demographics
NPI:1235385873
Name:ST. CHARLES VISION - BOUTTE LLC
Entity Type:Organization
Organization Name:ST. CHARLES VISION - BOUTTE LLC
Other - Org Name:ST. CHARLES VISION OUTLET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:504-866-7352
Mailing Address - Street 1:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:BOUTTE
Mailing Address - State:LA
Mailing Address - Zip Code:70039-0446
Mailing Address - Country:US
Mailing Address - Phone:985-785-8484
Mailing Address - Fax:985-785-8483
Practice Address - Street 1:13322 HIGHWAY 90
Practice Address - Street 2:SUITE L
Practice Address - City:BOUTTE
Practice Address - State:LA
Practice Address - Zip Code:70039-3039
Practice Address - Country:US
Practice Address - Phone:985-785-8484
Practice Address - Fax:985-785-8483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1451622Medicaid
LA5DR83Medicare PIN