Healthcare Provider Details

I. General information

NPI: 1154717593
Provider Name (Legal Business Name): NUCROWN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 04/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 LOUGHBOROUGH COMMONS
SAINT LOUIS MO
63111
US

IV. Provider business mailing address

211 E BROADWAY
ALTON IL
62002-6220
US

V. Phone/Fax

Practice location:
  • Phone: 314-741-8183
  • Fax: 314-741-4947
Mailing address:
  • Phone: 618-462-9818
  • Fax: 800-432-6004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTO2999
License Number StateMO

VIII. Authorized Official

Name: CHARLES D. MATTHEWS
Title or Position: PRESIDENT
Credential:
Phone: 618-462-9818