Provider Demographics
NPI:1538336086
Name:LEIVA, MAURO I (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:MAURO
Middle Name:
Last Name:LEIVA
Suffix:I
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 GAUSE BLVD E
Mailing Address - Street 2:SUITE 303
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-5442
Mailing Address - Country:US
Mailing Address - Phone:985-646-4428
Mailing Address - Fax:985-646-4426
Practice Address - Street 1:1850 GAUSE BLVD E
Practice Address - Street 2:SUITE 303
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-5434
Practice Address - Country:US
Practice Address - Phone:985-646-4428
Practice Address - Fax:985-646-4426
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA22048156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician