Healthcare Provider Details

I. General information

NPI: 1992854111
Provider Name (Legal Business Name): OPTICAL WEST INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 04/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 NORTH 7TH
WEST MONROE LA
71291
US

IV. Provider business mailing address

1110 NORTH 7TH
WEST MONROE LA
71291
US

V. Phone/Fax

Practice location:
  • Phone: 318-387-4388
  • Fax: 318-387-4343
Mailing address:
  • Phone: 318-387-4388
  • Fax: 318-387-4343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. BENJAMIN STEVEN DILLINGHAM
Title or Position: PRESIDENT
Credential:
Phone: 318-387-4388