MEDICARE: RIVERTOWN OPTICAL SHOP

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	152W00000X	Optometrist	1274431T	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821326737
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERTOWN OPTICAL SHOP

Provider Business Mailing Address
First Line	:	400 WILLIAMS BLVD
Second Line	:
City	:	KENNER
State	:	LA
Zip	:	70062-7632
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 WILLIAMS BLVD
Second Line	:
City	:	KENNER
State	:	LA
Zip	:	70062-7632
Country	:	US
Telephone Number	:	504-461-5500
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PAUL PROUET
Credential	:
Telephone Number	:	504-782-2990

Provider Enumeration Date	:	12/04/2009
Last Update Date	:	03/17/2011

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Directions to “RIVERTOWN OPTICAL SHOP ” Practice Location

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