Basic Information
| Provider Information | |||||||||
| NPI: | 1073550448 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YOUNG EYE CLINIC, A PROFESSIONAL MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 N MAGDALEN SQ | ||||||||
| Address2: | |||||||||
| City: | ABBEVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705104645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3378934452 | ||||||||
| FaxNumber: | 3378937870 | ||||||||
| Practice Location | |||||||||
| Address1: | 204 N MAGDALEN SQ | ||||||||
| Address2: | |||||||||
| City: | ABBEVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705104645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3378934452 | ||||||||
| FaxNumber: | 3378937870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 06/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | BROUSSARD | ||||||||
| AuthorizedOfficialFirstName: | EMILE | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3378934452 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 0583490001 | 01 | LA | DME | OTHER |