Provider Demographics
NPI:1558330316
Name:PIERCE OPTOMETRY, LLC
Entity Type:Organization
Organization Name:PIERCE OPTOMETRY, LLC
Other - Org Name:NORTHSIDE EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:318-251-3626
Mailing Address - Street 1:116 KILLGORE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-7084
Mailing Address - Country:US
Mailing Address - Phone:318-251-3626
Mailing Address - Fax:318-251-3330
Practice Address - Street 1:116 KILLGORE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-7084
Practice Address - Country:US
Practice Address - Phone:318-251-3626
Practice Address - Fax:318-251-3330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1000-294T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1550418Medicaid
LAT7623OtherBLUE CROSS AND BLUE SHIELD
LA1550418Medicaid
LA5CR66Medicare ID - Type Unspecified