Healthcare Provider Details

I. General information

NPI: 1588723837
Provider Name (Legal Business Name): FAMILY EYECARE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 11/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 S. BUSINESS ROUTE 5
CAMDENTON MO
65020-1887
US

IV. Provider business mailing address

PO BOX 1887
CAMDENTON MO
65020-1887
US

V. Phone/Fax

Practice location:
  • Phone: 573-346-5951
  • Fax: 573-346-3252
Mailing address:
  • Phone: 573-346-5951
  • Fax: 573-346-3252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02552
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTO3452
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02691
License Number StateMO

VIII. Authorized Official

Name: DR. DIANA MEADE SCOGGIN
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 573-346-5951