Healthcare Provider Details

I. General information

NPI: 1366037244
Provider Name (Legal Business Name): GATEWAY LOW VISION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 N NEW BALLAS RD STE 120
SAINT LOUIS MO
63141-6820
US

IV. Provider business mailing address

522 N NEW BALLAS RD STE 120
SAINT LOUIS MO
63141-6820
US

V. Phone/Fax

Practice location:
  • Phone: 314-517-5893
  • Fax: 314-312-6984
Mailing address:
  • Phone: 314-328-9919
  • Fax: 314-228-2104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. JILL M MOGIL
Title or Position: CLINICAL DIRECTOR
Credential: OD
Phone: 314-328-9919