Healthcare Provider Details

I. General information

NPI: 1548654981
Provider Name (Legal Business Name): AMERICAN EYEWEAR CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2015
Last Update Date: 06/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10275 WATSON RD
SAINT LOUIS MO
63127-1103
US

IV. Provider business mailing address

10275 WATSON RD
SAINT LOUIS MO
63127-1103
US

V. Phone/Fax

Practice location:
  • Phone: 314-962-9334
  • Fax: 314-962-8248
Mailing address:
  • Phone: 314-962-9334
  • Fax: 314-962-8248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberMOT02606
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. STEVEN M GOLDBERG
Title or Position: OWNER
Credential: O.D.
Phone: 314-629-7667