Healthcare Provider Details

I. General information

NPI: 1598755589
Provider Name (Legal Business Name): PELLEGRINE, INC DBA PEARLE VISION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11533 OLIVE BLVD
CREVE COEUR MO
63141-7110
US

IV. Provider business mailing address

11533 OLIVE BLVD
CREVE COEUR MO
63141-7110
US

V. Phone/Fax

Practice location:
  • Phone: 314-997-1377
  • Fax: 314-997-1378
Mailing address:
  • Phone: 314-997-1377
  • Fax: 314-997-1378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number14800888
License Number StateMO

VIII. Authorized Official

Name: MR. PETER J PELLEGRINE JR.
Title or Position: PRESIDENT
Credential:
Phone: 314-997-1377