Provider Demographics
NPI:1568651222
Name:VISION CLINIC LLC
Entity type:Organization
Organization Name:VISION CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:G
Authorized Official - Last Name:GERDES
Authorized Official - Suffix:II
Authorized Official - Credentials:OD
Authorized Official - Phone:318-335-3275
Mailing Address - Street 1:414 E 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:LA
Mailing Address - Zip Code:71463-2624
Mailing Address - Country:US
Mailing Address - Phone:318-335-3275
Mailing Address - Fax:318-335-3271
Practice Address - Street 1:414 E 7TH AVE
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:LA
Practice Address - Zip Code:71463-2624
Practice Address - Country:US
Practice Address - Phone:318-335-3275
Practice Address - Fax:318-335-3271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1339527T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5CM73OtherMEDICARE GROUP NUMBER