Provider Demographics
NPI:1356694434
Name:VISION SOURCE ALEXANDRIA LLC
Entity type:Organization
Organization Name:VISION SOURCE ALEXANDRIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LACY
Authorized Official - Middle Name:B
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:318-442-7787
Mailing Address - Street 1:5615B JACKSON STREET EXT
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2275
Mailing Address - Country:US
Mailing Address - Phone:318-442-7787
Mailing Address - Fax:318-443-1654
Practice Address - Street 1:5615B JACKSON STREET EXT
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2275
Practice Address - Country:US
Practice Address - Phone:318-442-7787
Practice Address - Fax:318-443-1654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA734-081T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1153486Medicaid
LA0439680001Medicare NSC
LA48912Medicare UPIN