Healthcare Provider Details

I. General information

NPI: 1033305966
Provider Name (Legal Business Name): CLARKSON OPTOMETRY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9540 MANCHESTER RD
ROCK HILL MO
63119
US

IV. Provider business mailing address

PO BOX 207158
DALLAS TX
75320-7158
US

V. Phone/Fax

Practice location:
  • Phone: 636-200-4393
  • Fax: 314-962-3909
Mailing address:
  • Phone: 636-200-4393
  • Fax: 636-527-0766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT03019
License Number StateMO

VIII. Authorized Official

Name: JAMES WACHTER
Title or Position: CPO/ VICE CHAIRMAN
Credential:
Phone: 636-200-4393