Healthcare Provider Details

I. General information

NPI: 1255310413
Provider Name (Legal Business Name): CLEARWATER VISION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2006
Last Update Date: 02/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 S MAIN ST
PIEDMONT MO
63957-1563
US

IV. Provider business mailing address

106 S MAIN ST
PIEDMONT MO
63957-1563
US

V. Phone/Fax

Practice location:
  • Phone: 573-223-7615
  • Fax:
Mailing address:
  • Phone: 573-223-7615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTO2426
License Number StateMO

VIII. Authorized Official

Name: DR. KENNETH DETRING
Title or Position: PARTNER
Credential: O.D.
Phone: 573-223-7615