Healthcare Provider Details

I. General information

NPI: 1144657099
Provider Name (Legal Business Name): NUCROWN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2013
Last Update Date: 04/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

856 ARNOLD COMMONS DR
ARNOLD MO
63010-2164
US

IV. Provider business mailing address

856 ARNOLD COMMONS DR
ARNOLD MO
63010-2164
US

V. Phone/Fax

Practice location:
  • Phone: 314-741-8183
  • Fax: 314-741-4947
Mailing address:
  • Phone: 636-321-4204
  • Fax: 636-321-4223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02999
License Number StateMO

VIII. Authorized Official

Name: CHARLES D. MATTHEWS
Title or Position: PRESIDENT
Credential:
Phone: 314-741-8183