Healthcare Provider Details

I. General information

NPI: 1366396889
Provider Name (Legal Business Name): REJUVENATE LIGHT AND VISION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2026
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N MASSEY BLVD
NIXA MO
65714-8324
US

IV. Provider business mailing address

220 N MASSEY BLVD
NIXA MO
65714-8324
US

V. Phone/Fax

Practice location:
  • Phone: 417-374-1088
  • Fax:
Mailing address:
  • Phone: 417-374-1088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: CADE JOHN KOWALLIS
Title or Position: OWNER
Credential: OD
Phone: 417-604-0188