Healthcare Provider Details

I. General information

NPI: 1770659864
Provider Name (Legal Business Name): VISION STREET EYE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 WESTMOUNT DR.
FARMINGTON MO
63640-0829
US

IV. Provider business mailing address

102 WESTMOUNT DR
FARMINGTON MO
63640-2970
US

V. Phone/Fax

Practice location:
  • Phone: 573-756-3170
  • Fax: 573-756-0173
Mailing address:
  • Phone: 573-756-3170
  • Fax: 573-756-0173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02599
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2000160791
License Number StateMO

VIII. Authorized Official

Name: DR. JASON T STREET
Title or Position: OWNER OPTOMETRIST
Credential: OD
Phone: 573-756-3170