Healthcare Provider Details

I. General information

NPI: 1700059656
Provider Name (Legal Business Name): DR. MICHAEL J. HAYNES A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2808 FORSYTHE AVENUE
MONROE LA
71201-3008
US

IV. Provider business mailing address

2808 FORSYTHE AVENUE
MONROE LA
71201-3008
US

V. Phone/Fax

Practice location:
  • Phone: 318-323-4994
  • Fax: 318-388-6913
Mailing address:
  • Phone: 318-323-4994
  • Fax: 318-388-6913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number891-26T
License Number StateLA

VIII. Authorized Official

Name: DR. MICHAEL J HAYNES
Title or Position: PRESIDENT
Credential: OD
Phone: 318-323-4994