MEDICARE: EYECARE SPECIALTIES OF MISSOURI 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		MO

General Provider Information

NPI Number	:	1720453251
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYECARE SPECIALTIES OF MISSOURI LLC

Provider Business Mailing Address
First Line	:	601 E RUSSELL AVE
Second Line	:	STE. A
City	:	WARRENSBURG
State	:	MO
Zip	:	64093-9605
Country	:	US
Telephone Number	:	660-747-2020
Fax Number	:	660-747-0574

Provider Business Practice Location Address
First Line	:	1652 SE BLUE PARKWAY
Second Line	:
City	:	LEES SUMMIT
State	:	MO
Zip	:	64063-3191
Country	:	US
Telephone Number	:	816-207-6085
Fax Number	:	816-600-5335

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. DEBBIE REYNOLDS
Credential	:
Telephone Number	:	660-747-2020

Provider Enumeration Date	:	12/09/2015
Last Update Date	:	06/02/2016

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