Healthcare Provider Details

I. General information

NPI: 1255478095
Provider Name (Legal Business Name): MISSOURI EYE ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 09/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11710 OLD BALLAS RD SUITE 102
SAINT LOUIS MO
63141-7076
US

IV. Provider business mailing address

11710 OLD BALLAS RD SUITE 102
SAINT LOUIS MO
63141-7076
US

V. Phone/Fax

Practice location:
  • Phone: 314-569-2020
  • Fax: 314-569-1596
Mailing address:
  • Phone: 314-569-2020
  • Fax: 314-569-1596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT03182
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number36602
License Number StateMO

VIII. Authorized Official

Name: DR. JOHN ARTHUR MCGREAL JR.
Title or Position: OWNER
Credential: OD
Phone: 314-569-2020