Healthcare Provider Details

I. General information

NPI: 1891294948
Provider Name (Legal Business Name): CORINNE LAURA LIGE B.C.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CORINNE LAURA COOK B.C.O.

II. Dates (important events)

Enumeration Date: 02/05/2018
Last Update Date: 02/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 N BALLAS RD STE C30
SAINT LOUIS MO
63131-2393
US

IV. Provider business mailing address

2821 N BALLAS RD STE C30
SAINT LOUIS MO
63131-2393
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-7585
  • Fax: 314-567-7083
Mailing address:
  • Phone: 314-567-7585
  • Fax: 314-567-7083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number09-318-21
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: