Healthcare Provider Details

I. General information

NPI: 1588239586
Provider Name (Legal Business Name): PEREZ BURGHART VISION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2021
Last Update Date: 05/21/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 N NEW BALLAS RD
SAINT LOUIS MO
63141-6715
US

IV. Provider business mailing address

745 N NEW BALLAS RD
SAINT LOUIS MO
63141-6715
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-7423
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE BURGHART
Title or Position: SOLE MEMBER
Credential: OD
Phone: 314-567-7423