Healthcare Provider Details

I. General information

NPI: 1366039075
Provider Name (Legal Business Name): VISION SURGICAL ARTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2020
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD STE 16A
SAINT LOUIS MO
63141-8239
US

IV. Provider business mailing address

621 S NEW BALLAS RD STE 16A
SAINT LOUIS MO
63141-8239
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6725
  • Fax:
Mailing address:
  • Phone: 314-251-6725
  • Fax: 314-251-6726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: LACY WILSON
Title or Position: BUSINESS MANAGER
Credential:
Phone: 314-251-6725