Provider Demographics
NPI:1366827586
Name:VAN, CAROLYN
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:VAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 JOHNSTON ST
Mailing Address - Street 2:APT 212
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-5645
Mailing Address - Country:US
Mailing Address - Phone:225-405-3792
Mailing Address - Fax:
Practice Address - Street 1:201 MEADOW FARM DR.
Practice Address - Street 2:INSIDE OF COSTCO
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508
Practice Address - Country:US
Practice Address - Phone:337-541-7040
Practice Address - Fax:337-541-7041
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1794-728AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist