Provider Demographics
NPI:1558502971
Name:EARL J PRIMO MS OD LLC
Entity Type:Organization
Organization Name:EARL J PRIMO MS OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EARL
Authorized Official - Middle Name:J
Authorized Official - Last Name:PRIMO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:985-867-8708
Mailing Address - Street 1:205 STONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-5819
Mailing Address - Country:US
Mailing Address - Phone:504-606-1701
Mailing Address - Fax:985-871-9953
Practice Address - Street 1:880 N HIGHWAY 190
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-5147
Practice Address - Country:US
Practice Address - Phone:985-867-8708
Practice Address - Fax:985-867-8711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-14
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1332-466T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1153796Medicaid
LA1153796Medicaid
LAU93601Medicare UPIN