=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457856296
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE CENTRAL MANSFIELD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2018
-----------------------------------------------------
Last Update Date | 03/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 405 POLK ST
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71052-2400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-872-0747
-----------------------------------------------------
Fax | 318-716-3376
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 313 GRIFFIN DR
-----------------------------------------------------
City | STONEWALL
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71078-5411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-963-1055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRADLY LARSON
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 318-872-0747
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1775-709AT
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------