Provider Demographics
NPI:1750662474
Name:MCCLURE, EDDIE DALE (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:DALE
Last Name:MCCLURE
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3153 E TEXAS ST
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3209
Mailing Address - Country:US
Mailing Address - Phone:225-753-0441
Mailing Address - Fax:225-753-3320
Practice Address - Street 1:5368 KENNESAW DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-2555
Practice Address - Country:US
Practice Address - Phone:225-753-0441
Practice Address - Fax:225-753-3320
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10-00013656156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1508876095OtherMEDICAID NPI NUMBER
LA1156612Medicaid