Healthcare Provider Details

I. General information

NPI: 1871778977
Provider Name (Legal Business Name): LAURIE FAMILY EYECARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 11/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 S. MAIN SUITE C
LAURIE MO
65037
US

IV. Provider business mailing address

PO BOX 1185
LAURIE MO
65038
US

V. Phone/Fax

Practice location:
  • Phone: 573-374-5222
  • Fax:
Mailing address:
  • Phone: 573-374-5222
  • Fax: 573-374-7351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTO3452
License Number StateMO

VIII. Authorized Official

Name: BRIAN EVELAND
Title or Position: PRESIDENT
Credential: OD
Phone: 573-374-5222