Provider Demographics
NPI:1366610933
Name:DIANE W WHALEY ON THE GO OPTICAL SERVICE
Entity type:Organization
Organization Name:DIANE W WHALEY ON THE GO OPTICAL SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:WHALEY
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:318-747-9227
Mailing Address - Street 1:2801 NORTHSIDE DR
Mailing Address - Street 2:STE 9
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-1700
Mailing Address - Country:US
Mailing Address - Phone:318-747-9227
Mailing Address - Fax:
Practice Address - Street 1:2801 NORTHSIDE DR
Practice Address - Street 2:STE B
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-5810
Practice Address - Country:US
Practice Address - Phone:318-747-9227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty