Provider Demographics
NPI:1255320123
Name:HIGHLAND CLINIC OPTICAL SHOP, LLC
Entity Type:Organization
Organization Name:HIGHLAND CLINIC OPTICAL SHOP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-798-4539
Mailing Address - Street 1:1455 E BERT KOUNS LOOP
Mailing Address - Street 2:SUITE #300
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5634
Mailing Address - Country:US
Mailing Address - Phone:318-798-4614
Mailing Address - Fax:
Practice Address - Street 1:1455 E BERT KOUNS LOOP
Practice Address - Street 2:SUITE #300
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5634
Practice Address - Country:US
Practice Address - Phone:318-798-4614
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CA16Medicare ID - Type UnspecifiedMEDICARE NUMBER