=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639258726
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE CARE & COSMETIC CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2006
-----------------------------------------------------
Last Update Date | 08/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2421 CHURCH ST
-----------------------------------------------------
City | ZACHARY
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70791-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-654-1061
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2421 CHURCH ST
-----------------------------------------------------
City | ZACHARY
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70791-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-654-1061
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING / CODING MANAGER
-----------------------------------------------------
Name | MRS. KIMBERLY J SCHOBER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 225-654-1061
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------