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General NPI Number Information
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NPI Number | 1568634038
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Entity Type | Organization
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Legal Business Name | THIBODAUX VISION CENTER INC
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Dates
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Enumeration Date | 03/25/2008
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Last Update Date | 03/25/2008
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Provider Practice Location Address
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Address Line | 640 ST CHARLES ST
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City | THIBODAUX
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State | LA
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Zip | 70301
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Country | US
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Telephone | 985-446-1717
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Fax | 985-446-9542
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Provider Business Mailing Address
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Address Line | PO BOX 72
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City | THIBODAUX
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State | LA
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Zip | 70301-0072
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Country | US
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Telephone | 985-446-1717
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Fax | 985-446-9542
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARK JOSEPH ROY III
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Credential | OD
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Telephone | 985-446-1717
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1354488T
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License Number State | LA
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