Provider Demographics
NPI:1952428005
Name:ST. CHARLES VISION OUTLET MANDEVILLE, LLC
Entity Type:Organization
Organization Name:ST. CHARLES VISION OUTLET MANDEVILLE, LLC
Other - Org Name:ST. CHARLES VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:G
Authorized Official - Last Name:ROUSSEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-626-8103
Mailing Address - Street 1:1844 N. CAUSEWAY BLVD.
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471
Mailing Address - Country:US
Mailing Address - Phone:985-626-8103
Mailing Address - Fax:985-626-5571
Practice Address - Street 1:1844 N. CAUSEWAY BLVD.
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471
Practice Address - Country:US
Practice Address - Phone:985-626-8103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1318453T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA929236YSSXMedicare PIN
LA5CN50Medicare PIN
LAU86591Medicare UPIN
LA5281890001Medicare NSC