Provider Demographics
NPI:1699455949
Name:RIVERTOWN OPTICAL LLC
Entity type:Organization
Organization Name:RIVERTOWN OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARION
Authorized Official - Middle Name:POLLET
Authorized Official - Last Name:FAVRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-641-1195
Mailing Address - Street 1:401 PONTCHARTRAIN DRIVE STE A
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458
Mailing Address - Country:US
Mailing Address - Phone:985-641-1195
Mailing Address - Fax:985-641-1193
Practice Address - Street 1:401 PONTCHARTRAIN DRIVE STE A
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458
Practice Address - Country:US
Practice Address - Phone:985-641-1195
Practice Address - Fax:985-641-1193
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVERTOWN OPTICAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1541176Medicaid