Healthcare Provider Details

I. General information

NPI: 1568415776
Provider Name (Legal Business Name): MITCHELL EYE CARE ASSOCIATES, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 12/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 SAINT MARY ST
THIBODAUX LA
70301-2641
US

IV. Provider business mailing address

425 SAINT MARY ST
THIBODAUX LA
70301-2641
US

V. Phone/Fax

Practice location:
  • Phone: 985-447-2393
  • Fax: 985-447-2399
Mailing address:
  • Phone: 985-447-2393
  • Fax: 985-447-2399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1412-554T
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number1411-553T
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number1412-554T
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number1411-553T
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number1411-553T
License Number StateLA
# 6
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number1412-554T
License Number StateLA
# 7
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1411-553T
License Number StateLA

VIII. Authorized Official

Name: DR. DAVID MITCHELL
Title or Position: MANAGER
Credential: O.D.
Phone: 985-447-2393