Healthcare Provider Details

I. General information

NPI: 1568873602
Provider Name (Legal Business Name): OTIS OPTOMETRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 07/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 CECIL ST
CAMDENTON MO
65020-7057
US

IV. Provider business mailing address

1939 WENTZVILLE PKWY STE 166
WENTZVILLE MO
63385-3424
US

V. Phone/Fax

Practice location:
  • Phone: 573-317-9279
  • Fax: 888-841-1312
Mailing address:
  • Phone: 636-812-3821
  • Fax: 888-841-1312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTO3134
License Number StateMO

VIII. Authorized Official

Name: MR. MATT DAVID WICKHAM
Title or Position: OWNER
Credential: O.D.
Phone: 314-276-1228