Provider Demographics
NPI:1912257056
Name:MELINDA LEGG OD A PROFESSIONAL OPTOMETRY CORPORATION
Entity Type:Organization
Organization Name:MELINDA LEGG OD A PROFESSIONAL OPTOMETRY CORPORATION
Other - Org Name:MELINDA LEGG OD A PROFESSIONAL OPTOMETRY CORPORATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:LEGG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:318-387-7257
Mailing Address - Street 1:303 MCMILLAN RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-8316
Mailing Address - Country:US
Mailing Address - Phone:318-387-7257
Mailing Address - Fax:
Practice Address - Street 1:303 MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-8316
Practice Address - Country:US
Practice Address - Phone:318-387-7257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-17
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1557-589T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2315048Medicaid
LA2315048Medicaid