Healthcare Provider Details

I. General information

NPI: 1417428509
Provider Name (Legal Business Name): SUCCESS VISION EYECARE OF CAPE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3019 WILLIAM ST STE 102
CAPE GIRARDEAU MO
63703-6385
US

IV. Provider business mailing address

5312 W 41ST ST
TULSA OK
74107-6110
US

V. Phone/Fax

Practice location:
  • Phone: 918-895-1700
  • Fax:
Mailing address:
  • Phone: 918-895-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: ROSE DAVYDOVA
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 918-800-2020