Healthcare Provider Details

I. General information

NPI: 1811500069
Provider Name (Legal Business Name): PEC CHESTERFIELD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2020
Last Update Date: 08/27/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 CLARKSON RD STE 102
ELLISVILLE MO
63011-2271
US

IV. Provider business mailing address

4111 N ILLINOIS ST
SWANSEA IL
62226-7609
US

V. Phone/Fax

Practice location:
  • Phone: 636-725-2020
  • Fax:
Mailing address:
  • Phone: 618-234-3053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DIRK MASSIE
Title or Position: OWNER
Credential: OD
Phone: 618-234-3053