Provider Demographics
NPI:1457856296
Name:EYE CENTRAL MANSFIELD LLC
Entity Type:Organization
Organization Name:EYE CENTRAL MANSFIELD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:318-872-0747
Mailing Address - Street 1:313 GRIFFIN DR
Mailing Address - Street 2:
Mailing Address - City:STONEWALL
Mailing Address - State:LA
Mailing Address - Zip Code:71078-5411
Mailing Address - Country:US
Mailing Address - Phone:318-963-1055
Mailing Address - Fax:
Practice Address - Street 1:405 POLK ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:LA
Practice Address - Zip Code:71052-2400
Practice Address - Country:US
Practice Address - Phone:318-872-0747
Practice Address - Fax:318-716-3376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1775-709AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2379054Medicaid