Healthcare Provider Details

I. General information

NPI: 1811205099
Provider Name (Legal Business Name): CATHY EDWARDS O.D. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2010
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COMMERCIAL LN
PINEVILLE MO
64856-7069
US

IV. Provider business mailing address

100 COMMERCIAL LN
PINEVILLE MO
64856-7069
US

V. Phone/Fax

Practice location:
  • Phone: 417-226-5850
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02908
License Number StateMO

VIII. Authorized Official

Name: DR. CATHY EDWARDS
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 417-226-5850