Provider Demographics
NPI:1497707780
Name:SHENANDOAH EYE CLINIC
Entity Type:Organization
Organization Name:SHENANDOAH EYE CLINIC
Other - Org Name:THE LENS SOURCE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OPTOMETRIST/OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:F
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:III
Authorized Official - Credentials:OD
Authorized Official - Phone:225-755-3937
Mailing Address - Street 1:5237 JONES CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-2124
Mailing Address - Country:US
Mailing Address - Phone:225-755-3937
Mailing Address - Fax:225-755-2272
Practice Address - Street 1:5237 JONES CREEK ROAD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-2124
Practice Address - Country:US
Practice Address - Phone:225-755-3937
Practice Address - Fax:225-755-2272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X, 152WC0802X, 152WS0006X
LALA773206T332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0699540001OtherMEDICARE SUPPLIER #
LA1196519Medicaid
LA496905304Medicare ID - Type Unspecified
LA1196519Medicaid