MEDICARE: REJUVENATE LIGHT AND VISION CENTER PC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	152WC0802X	Corneal and Contact Management Optometrist
2	152WP0200X	Pediatric Optometrist
3	152WV0400X	Vision Therapy Optometrist
4	152W00000X	Optometrist

General Provider Information

NPI Number	:	1366396889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REJUVENATE LIGHT AND VISION CENTER PC

Provider Business Mailing Address
First Line	:	220 N MASSEY BLVD
Second Line	:
City	:	NIXA
State	:	MO
Zip	:	65714-8324
Country	:	US
Telephone Number	:	417-374-1088
Fax Number	:

Provider Business Practice Location Address
First Line	:	220 N MASSEY BLVD
Second Line	:
City	:	NIXA
State	:	MO
Zip	:	65714-8324
Country	:	US
Telephone Number	:	417-374-1088
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CADE JOHN KOWALLIS
Credential	:	OD
Telephone Number	:	417-604-0188

Provider Enumeration Date	:	02/23/2026
Last Update Date	:	02/23/2026

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