=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811220775
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISION CENTER OF THE SOUTH, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2009
-----------------------------------------------------
Last Update Date | 09/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4200 CANAL ST SUITE D
-----------------------------------------------------
City | NEW ORLEANS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70119-5984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-482-1290
-----------------------------------------------------
Fax | 504-482-1292
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4200 CANAL ST SUITE D
-----------------------------------------------------
City | NEW ORLEANS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70119-5984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-482-1290
-----------------------------------------------------
Fax | 504-482-1292
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER-OPTOMETRIST
-----------------------------------------------------
Name | DR. MADELINE MAXINE BORNE
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 504-482-1290
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 1007-345T
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------