Provider Demographics
NPI:1275617425
Name:VISION OPTIQUE INC
Entity Type:Organization
Organization Name:VISION OPTIQUE INC
Other - Org Name:VISION OPTIQUE MDV
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRUEING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-727-9948
Mailing Address - Street 1:PO BOX 1950
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70470-1950
Mailing Address - Country:US
Mailing Address - Phone:985-727-9948
Mailing Address - Fax:985-237-6008
Practice Address - Street 1:2997 HIGHWAY 190
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3298
Practice Address - Country:US
Practice Address - Phone:985-727-9948
Practice Address - Fax:985-237-6008
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VISION OPTIQUE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-24
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0323650006Medicare NSC