Healthcare Provider Details

I. General information

NPI: 1366867491
Provider Name (Legal Business Name): SPECIAL CARE VISION OF MISSOURI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2014
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 WASHINGTON ST
CHILLICOTHEE MO
64601-1306
US

IV. Provider business mailing address

12910 SHELBYVILLE RD 300
LOUISVILLE KY
40243-1593
US

V. Phone/Fax

Practice location:
  • Phone: 502-244-2457
  • Fax:
Mailing address:
  • Phone: 502-244-2457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02343
License Number StateMO

VIII. Authorized Official

Name: JESSICA VELTEN
Title or Position: DIRECTOR OF BILLING
Credential: CPC
Phone: 502-244-2457