Healthcare Provider Details

I. General information

NPI: 1285804286
Provider Name (Legal Business Name): MCCULLOUGH EYECARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 WALNUT ST
FESTUS MO
63028-1850
US

IV. Provider business mailing address

202 WALNUT ST
FESTUS MO
63028-1850
US

V. Phone/Fax

Practice location:
  • Phone: 636-937-3130
  • Fax: 636-937-7202
Mailing address:
  • Phone: 636-937-3130
  • Fax: 636-937-7202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2002014341
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. JAROD LANCE MCCULLOUGH
Title or Position: OWNER/OPTOMETRIST
Credential: O.D.
Phone: 636-937-3130