Healthcare Provider Details

I. General information

NPI: 1053427435
Provider Name (Legal Business Name): EYECARE SPECIALTIES OF MISSOURI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 04/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 E OHIO ST
CLINTON MO
64735-2458
US

IV. Provider business mailing address

601 E RUSSELL AVE SUITE A
WARRENSBURG MO
64093-9605
US

V. Phone/Fax

Practice location:
  • Phone: 660-885-7116
  • Fax:
Mailing address:
  • Phone: 660-747-2020
  • Fax: 660-747-0574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. JASON STEVEN LAKE
Title or Position: DR/ OWNER
Credential: OD
Phone: 660-885-7116