Healthcare Provider Details

I. General information

NPI: 1770617342
Provider Name (Legal Business Name): BOREING VISION CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 03/15/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W MCNEESE ST
LAKE CHARLES LA
70605-5528
US

IV. Provider business mailing address

500 W MCNEESE ST
LAKE CHARLES LA
70605-5528
US

V. Phone/Fax

Practice location:
  • Phone: 337-474-6161
  • Fax: 337-474-6474
Mailing address:
  • Phone: 337-474-6161
  • Fax: 337-474-6474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number904-130T
License Number StateLA

VIII. Authorized Official

Name: DR. JENNIFER SMITH
Title or Position: OWNER
Credential: OPTOMETRIST
Phone: 337-474-6161