Provider Demographics
NPI:1205028057
Name:W E MARIONNEAUX JR OD LLC
Entity type:Organization
Organization Name:W E MARIONNEAUX JR OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:MARIONNEAUX
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:318-435-5145
Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-0910
Mailing Address - Country:US
Mailing Address - Phone:318-435-5145
Mailing Address - Fax:318-435-9476
Practice Address - Street 1:6609 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-2763
Practice Address - Country:US
Practice Address - Phone:318-435-5145
Practice Address - Fax:318-435-9476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA712 014 T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5CJ37Medicare PIN
LA5388880001Medicare NSC