Healthcare Provider Details

I. General information

NPI: 1902379266
Provider Name (Legal Business Name): EL DORADO VISION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2019
Last Update Date: 04/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E HOSPITAL RD
EL DORADO SPRINGS MO
64744
US

IV. Provider business mailing address

701 E HOSPITAL RD
EL DORADO SPRINGS MO
64744
US

V. Phone/Fax

Practice location:
  • Phone: 417-876-6052
  • Fax: 417-876-3352
Mailing address:
  • Phone: 417-876-6052
  • Fax: 417-876-3352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LAURA B MONTGOMERY
Title or Position: OWNER/OPTOMETRIST
Credential: O.D.
Phone: 417-777-9000