Provider Demographics
NPI:1740571751
Name:DESOTO FAMILY EYE CARE LLC
Entity Type:Organization
Organization Name:DESOTO FAMILY EYE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETE
Authorized Official - Middle Name:
Authorized Official - Last Name:WARDELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:318-332-6171
Mailing Address - Street 1:946 KEYSER AVE
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-6266
Mailing Address - Country:US
Mailing Address - Phone:318-332-6171
Mailing Address - Fax:318-352-3145
Practice Address - Street 1:946 KEYSER AVE
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-6266
Practice Address - Country:US
Practice Address - Phone:318-332-6171
Practice Address - Fax:318-352-3145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-25
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1419-543T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty