Healthcare Provider Details

I. General information

NPI: 1427551894
Provider Name (Legal Business Name): TARY VISION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 03/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 RONNIES PLZ
SAINT LOUIS MO
63126-3552
US

IV. Provider business mailing address

844 KONERT HILL DR
FENTON MO
63026-7176
US

V. Phone/Fax

Practice location:
  • Phone: 314-843-2020
  • Fax: 314-843-2021
Mailing address:
  • Phone: 636-208-2832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2014018412
License Number StateMO

VIII. Authorized Official

Name: ASHLEY NICOLE TARY
Title or Position: SOLE MBR
Credential: OD
Phone: 636-208-2832