Healthcare Provider Details

I. General information

NPI: 1609434604
Provider Name (Legal Business Name): DANIEL AUSTIN BOONE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 VILLAGE CENTER ST
NIXA MO
65714-7824
US

IV. Provider business mailing address

107 VILLAGE CENTER ST
NIXA MO
65714-7824
US

V. Phone/Fax

Practice location:
  • Phone: 417-725-0000
  • Fax: 417-725-0001
Mailing address:
  • Phone: 417-725-0000
  • Fax: 417-725-0001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2019016836
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: