MEDICARE: PEC WARSON, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

General Provider Information

NPI Number	:	1063058386
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEC WARSON, LLC

Provider Business Mailing Address
First Line	:	4111 N ILLINOIS ST
Second Line	:
City	:	SWANSEA
State	:	IL
Zip	:	62226-7609
Country	:	US
Telephone Number	:	618-234-3053
Fax Number	:

Provider Business Practice Location Address
First Line	:	9973 MANCHESTER RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63122-1915
Country	:	US
Telephone Number	:	618-234-3053
Fax Number	:

Authorized Official
Title or Position	:	OPTOMETRIST/OD
Name	:	DIRK MASSIE
Credential	:	OD
Telephone Number	:	618-234-3053

Provider Enumeration Date	:	11/21/2019
Last Update Date	:	02/26/2026

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