Provider Demographics
NPI:1689846487
Name:THE OPTICAL SHOPPE
Entity Type:Organization
Organization Name:THE OPTICAL SHOPPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:FAJONI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-345-0050
Mailing Address - Street 1:PO BOX 2988
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70404-2988
Mailing Address - Country:US
Mailing Address - Phone:985-345-0050
Mailing Address - Fax:985-345-5800
Practice Address - Street 1:1615 SW RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-6113
Practice Address - Country:US
Practice Address - Phone:985-345-1513
Practice Address - Fax:985-345-5800
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYE PHYSICIANS & SURGEONS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-01
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1980421Medicaid
LA1980421Medicaid