Healthcare Provider Details

I. General information

NPI: 1508875790
Provider Name (Legal Business Name): MISSOURI EYE AND VISION ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 S BUSINESS ROUTE 5
CAMDENTON MO
65020-9589
US

IV. Provider business mailing address

PO BOX 1887
CAMDENTON MO
65020-1887
US

V. Phone/Fax

Practice location:
  • Phone: 573-346-5951
  • Fax:
Mailing address:
  • Phone: 573-346-5951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT03452
License Number StateMO

VIII. Authorized Official

Name: DR. BRIAN EVELAND
Title or Position: PRESIDENT
Credential: OD
Phone: 573-745-0419