Provider Demographics
NPI:1023340114
Name:EYEWEAR BOUTIQUE, INC
Entity type:Organization
Organization Name:EYEWEAR BOUTIQUE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHRISTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-948-9504
Mailing Address - Street 1:232 N UNION ST
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-6208
Mailing Address - Country:US
Mailing Address - Phone:337-948-9504
Mailing Address - Fax:337-942-3545
Practice Address - Street 1:232 N UNION ST
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-6208
Practice Address - Country:US
Practice Address - Phone:337-948-9504
Practice Address - Fax:337-942-3545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-01
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA793005T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0158790001OtherPTAN
LA1477722460OtherCIGNA/PALMETTO
LA5DP00Medicare PIN
LA1023340114Medicare PIN