Provider Demographics
NPI:1437320405
Name:EYEMAX FAMILY OPTICAL
Entity Type:Organization
Organization Name:EYEMAX FAMILY OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICAL STORE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-262-8141
Mailing Address - Street 1:11424 SULLIVAN RD
Mailing Address - Street 2:BLDG A SUITE A
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70818-3615
Mailing Address - Country:US
Mailing Address - Phone:225-262-8141
Mailing Address - Fax:225-262-8142
Practice Address - Street 1:11424 SULLIVAN RD
Practice Address - Street 2:BLDG A SUITE A
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70818-3615
Practice Address - Country:US
Practice Address - Phone:225-262-8141
Practice Address - Fax:225-262-8142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6872006003332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier