Healthcare Provider Details

I. General information

NPI: 1043495062
Provider Name (Legal Business Name): T M SWINGER & D V MCKILLIP, PTR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 07/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 KING AVE
PORTAGEVILLE MO
63873-1441
US

IV. Provider business mailing address

306 KING AVE
PORTAGEVILLE MO
63873-1441
US

V. Phone/Fax

Practice location:
  • Phone: 573-379-5235
  • Fax:
Mailing address:
  • Phone: 573-379-5235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02167
License Number StateMO

VIII. Authorized Official

Name: VICKIE L HURLEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 573-379-5235