MEDICARE: ALTENBERND FAMILY EYE CARE, 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	152WC0802X	Corneal and Contact Management Optometrist	TO3366	MO

General Provider Information

NPI Number	:	1952725210
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALTENBERND FAMILY EYE CARE, LLC

Provider Business Mailing Address
First Line	:	5445 TELEGRAPH RD
Second Line	:	SUITE 119
City	:	SAINT LOUIS
State	:	MO
Zip	:	63129-3500
Country	:	US
Telephone Number	:	314-845-0770
Fax Number	:	314-845-0814

Provider Business Practice Location Address
First Line	:	5445 TELEGRAPH RD
Second Line	:	SUITE 119
City	:	SAINT LOUIS
State	:	MO
Zip	:	63129-3500
Country	:	US
Telephone Number	:	314-845-0770
Fax Number	:	314-845-0814

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. THOMAS WILLIAM ALTENBERND
Credential	:	O.D.
Telephone Number	:	314-477-0314

Provider Enumeration Date	:	02/06/2014
Last Update Date	:	02/06/2014

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