Healthcare Provider Details

I. General information

NPI: 1316278013
Provider Name (Legal Business Name): OSAGE BEACH FAMILY EYECARE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2010
Last Update Date: 09/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5962 HIGHWAY 54
OSAGE BEACH MO
65065-3338
US

IV. Provider business mailing address

5962 HIGHWAY 54
OSAGE BEACH MO
65065-3338
US

V. Phone/Fax

Practice location:
  • Phone: 573-552-8569
  • Fax:
Mailing address:
  • Phone: 573-552-8569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberT03438
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberT03438
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberT03438
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License NumberT03438
License Number State
# 5
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberT03438
License Number State
# 6
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License NumberT03438
License Number StateMO
# 7
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT03438
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. BRIAN R. EVELAND
Title or Position: PRESIDENT
Credential: O.D.
Phone: 573-552-8569