Healthcare Provider Details

I. General information

NPI: 1386044808
Provider Name (Legal Business Name): EYE CENTRAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2014
Last Update Date: 09/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8889 JEWELLA AVE STE C
SHREVEPORT LA
71118-2138
US

IV. Provider business mailing address

8889 JEWELLA AVE STE C
SHREVEPORT LA
71118-2138
US

V. Phone/Fax

Practice location:
  • Phone: 318-686-5227
  • Fax: 318-686-5283
Mailing address:
  • Phone: 318-686-5227
  • Fax: 318-686-5283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1775-709T
License Number StateLA

VIII. Authorized Official

Name: DR. BRADLY LARSON
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 318-686-5227