MEDICARE: EYEMAX FAMILY OPTICAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier	6872006003	LA

General Provider Information

NPI Number	:	1437320405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYEMAX FAMILY OPTICAL

Provider Business Mailing Address
First Line	:	11424 SULLIVAN RD
Second Line	:	BLDG A SUITE A
City	:	BATON ROUGE
State	:	LA
Zip	:	70818-3615
Country	:	US
Telephone Number	:	225-262-8141
Fax Number	:	225-262-8142

Provider Business Practice Location Address
First Line	:	11424 SULLIVAN RD
Second Line	:	BLDG A SUITE A
City	:	BATON ROUGE
State	:	LA
Zip	:	70818-3615
Country	:	US
Telephone Number	:	225-262-8141
Fax Number	:	225-262-8142

Authorized Official
Title or Position	:	OPTICAL STORE MANAGER
Name	:	MS. DONNA LYNN DECKER
Credential	:
Telephone Number	:	225-262-8141

Provider Enumeration Date	:	03/18/2008
Last Update Date	:	03/18/2008

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