Healthcare Provider Details

I. General information

NPI: 1528334182
Provider Name (Legal Business Name): EYE ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12990 MANCHESTER RD SUITE 105
SAINT LOUIS MO
63131-1860
US

IV. Provider business mailing address

12990 MANCHESTER RD STE 103
SAINT LOUIS MO
63131-1860
US

V. Phone/Fax

Practice location:
  • Phone: 314-686-4200
  • Fax: 314-686-4201
Mailing address:
  • Phone: 866-226-9156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER LYNN KILLOREN
Title or Position: ADMINISTRATOR
Credential:
Phone: 314-686-4200