Healthcare Provider Details

I. General information

NPI: 1790920379
Provider Name (Legal Business Name): LUCAS OPTOMETRY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2008
Last Update Date: 12/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3165 S GRAND BLVD
SAINT LOUIS MO
63118-1021
US

IV. Provider business mailing address

3165 S GRAND BLVD
SAINT LOUIS MO
63118-1021
US

V. Phone/Fax

Practice location:
  • Phone: 314-772-3737
  • Fax: 314-664-7722
Mailing address:
  • Phone: 314-772-3737
  • Fax: 314-664-7722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTO2350
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTO2570
License Number StateMO

VIII. Authorized Official

Name: DR. TODD N. LUCAS
Title or Position: VICE PRESIDENT
Credential: O.D.
Phone: 314-772-3737