Healthcare Provider Details

I. General information

NPI: 1588711725
Provider Name (Legal Business Name): MEXICO EYE CENTER, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 12/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2753 S CLARK ST
MEXICO MO
65265-3720
US

IV. Provider business mailing address

2753 S CLARK ST
MEXICO MO
65265-3720
US

V. Phone/Fax

Practice location:
  • Phone: 573-581-8668
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number13553208
License Number StateMO

VIII. Authorized Official

Name: LEANNA MILLARD
Title or Position: ASSISTANT
Credential:
Phone: 573-581-8668