Healthcare Provider Details

I. General information

NPI: 1851454151
Provider Name (Legal Business Name): DOWNTOWN CLINIC OF OPTOMETRY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 OLIVE ST SUITE 420
SAINT LOUIS MO
63101-2338
US

IV. Provider business mailing address

720 OLIVE ST SUITE 420
SAINT LOUIS MO
63101-2338
US

V. Phone/Fax

Practice location:
  • Phone: 314-231-0581
  • Fax: 314-231-2690
Mailing address:
  • Phone: 314-231-0581
  • Fax: 314-231-2690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT2320
License Number StateMO

VIII. Authorized Official

Name: DR. MORIO MIYAMOTO
Title or Position: PRESIDENT
Credential: O.D.
Phone: 314-231-0581