# DR. MICHAEL WADE JORGENSEN OD LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1144677899
- **Authorized official:** DR. MICHAEL WADE JORGENSEN OD (OWNER/DOCTOR)
- **Authorized official phone:** (318) 935-5080

## Contact information

- **Practice address:** 187 BURT BLVD, STE A, BENTON, LA 71006-4905
- **Practice address phone:** (318) 935-5080
- **Practice address fax:** (318) 935-5085
- **Mailing address:** 187 BURT BLVD, STE A, BENTON, LA 71006-4905
- **Mailing address phone:** (318) 935-5080
- **Mailing address fax:** (318) 935-5085

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 152W00000X | Optometrist | 1590623T | LA | Yes |

## Other

- **Enumeration date:** 05/23/2016
- **Last updated:** 05/23/2016

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 2394495 | — | LA |