MEDICARE: BOREING VISION CLINIC INC

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	152WV0400X	Vision Therapy Optometrist	904-130T	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BLUECROSS BLUESHIELD	OTHER	LA	4318819170

General Provider Information

NPI Number	:	1770617342
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOREING VISION CLINIC INC

Provider Business Mailing Address
First Line	:	500 W MCNEESE ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-5528
Country	:	US
Telephone Number	:	337-474-6161
Fax Number	:	337-474-6474

Provider Business Practice Location Address
First Line	:	500 W MCNEESE ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-5528
Country	:	US
Telephone Number	:	337-474-6161
Fax Number	:	337-474-6474

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JENNIFER SMITH
Credential	:	OPTOMETRIST
Telephone Number	:	337-474-6161

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	03/15/2022

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