Healthcare Provider Details

I. General information

NPI: 1841426210
Provider Name (Legal Business Name): EYE & VISION REGENERATION GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2009
Last Update Date: 05/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 CHESTERFIELD TOWNE CTR
CHESTERFIELD MO
63005-1257
US

IV. Provider business mailing address

219 CHESTERFIELD TOWNE CTR
CHESTERFIELD MO
63005-1257
US

V. Phone/Fax

Practice location:
  • Phone: 636-449-7400
  • Fax:
Mailing address:
  • Phone: 636-449-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTO2796
License Number StateMO

VIII. Authorized Official

Name: DR. EDWARD S. JARKA
Title or Position: PRESIDENT
Credential: O.D.
Phone: 636-449-7400