Provider Demographics
NPI:1740339035
Name:OPTICAL SHOP OF ACADIANA
Entity type:Organization
Organization Name:OPTICAL SHOP OF ACADIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:G
Authorized Official - Last Name:IPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-235-4665
Mailing Address - Street 1:500 SAINT LANDRY ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-4626
Mailing Address - Country:US
Mailing Address - Phone:337-235-4665
Mailing Address - Fax:337-235-0246
Practice Address - Street 1:500 SAINT LANDRY ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-4626
Practice Address - Country:US
Practice Address - Phone:337-235-4665
Practice Address - Fax:337-235-0246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1476633Medicaid
LA1476633Medicaid