Healthcare Provider Details

I. General information

NPI: 1548399561
Provider Name (Legal Business Name): DES PERES EYE SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 314-686-4200
  • Fax: 314-686-4217
Mailing address:
  • Phone: 314-686-4200
  • Fax: 314-686-4217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateMO

VIII. Authorized Official

Name: MS. MELANIE KOFRON
Title or Position: ADMINISTRATOR
Credential: MHA
Phone: 314-686-4200