Provider Demographics
NPI:1942487087
Name:DR ELVIS SURLES A PROFESSIONAL OPTOMETRY CORPORATION
Entity Type:Organization
Organization Name:DR ELVIS SURLES A PROFESSIONAL OPTOMETRY CORPORATION
Other - Org Name:SURLES OPTICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:LORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-387-5657
Mailing Address - Street 1:2209 FORSYTHE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3643
Mailing Address - Country:US
Mailing Address - Phone:318-387-5657
Mailing Address - Fax:318-325-8472
Practice Address - Street 1:2209 FORSYTHE AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3643
Practice Address - Country:US
Practice Address - Phone:318-387-5657
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA19643152W00000X
LA717127T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1946192Medicaid
5F649Medicare UPIN
LA0750460001Medicare NSC
LA49455 5F649Medicare UPIN
49455Medicare PIN