Healthcare Provider Details

I. General information

NPI: 1770664625
Provider Name (Legal Business Name): FONTANA EYECARE ASSOCIATES, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 HAMPTON VILLAGE PLZ SUITE 249
SAINT LOUIS MO
63109-2128
US

IV. Provider business mailing address

16 HAMPTON VILLAGE PLZ SUITE 249
SAINT LOUIS MO
63109-2128
US

V. Phone/Fax

Practice location:
  • Phone: 314-353-6171
  • Fax:
Mailing address:
  • Phone: 314-353-6171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberT02260
License Number StateMO

VIII. Authorized Official

Name: PAUL DOUGLAS BECHERER
Title or Position: MANAGER
Credential: O.D.
Phone: 314-353-6171