Healthcare Provider Details

I. General information

NPI: 1063408169
Provider Name (Legal Business Name): LISA K PARKS OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 W JEFFERSON ST
CLINTON MO
64735-2061
US

IV. Provider business mailing address

106 W JEFFERSON ST
CLINTON MO
64735-2061
US

V. Phone/Fax

Practice location:
  • Phone: 660-885-2800
  • Fax: 660-885-5353
Mailing address:
  • Phone: 660-885-2800
  • Fax: 660-885-5353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTO2752
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: