Healthcare Provider Details

I. General information

NPI: 1295371946
Provider Name (Legal Business Name): PEC SOUTH COUNTY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2019
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4412 TELEGRAPH RD
SAINT LOUIS MO
63129-3316
US

IV. Provider business mailing address

4111 N ILLINOIS ST
SWANSEA IL
62226-7609
US

V. Phone/Fax

Practice location:
  • Phone: 618-234-3053
  • Fax:
Mailing address:
  • Phone: 618-234-3053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State

VIII. Authorized Official

Name: DIRK MASSIE
Title or Position: OPTOMETRIST/OWNER
Credential: OD
Phone: 618-234-3053