Provider Demographics
NPI:1689867350
Name:SLIDELL OPTICS INC
Entity Type:Organization
Organization Name:SLIDELL OPTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTICAL SHOP
Authorized Official - Prefix:MRS
Authorized Official - First Name:BONITA
Authorized Official - Middle Name:RUBLI
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-641-9767
Mailing Address - Street 1:2241 GAUSE BLVD
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-4232
Mailing Address - Country:US
Mailing Address - Phone:985-641-9767
Mailing Address - Fax:985-641-9319
Practice Address - Street 1:2241 GAUSE BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-4232
Practice Address - Country:US
Practice Address - Phone:985-641-9767
Practice Address - Fax:985-641-9319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0701710001Medicare NSC
LA49241Medicare PIN