Provider Demographics
NPI:1750639043
Name:THE LENS SOURCE
Entity Type:Organization
Organization Name:THE LENS SOURCE
Other - Org Name:SHENANDOAH EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:SMITH
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:ABO
Authorized Official - Phone:225-892-0450
Mailing Address - Street 1:5237 JONES CREEK RD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-2124
Mailing Address - Country:US
Mailing Address - Phone:225-755-3937
Mailing Address - Fax:225-755-2272
Practice Address - Street 1:5237 JONES CREEK RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-2124
Practice Address - Country:US
Practice Address - Phone:225-755-3937
Practice Address - Fax:225-755-2272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1624772Medicaid