Healthcare Provider Details

I. General information

NPI: 1619139367
Provider Name (Legal Business Name): EYEWEARHAUS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 N NEW BALLAS RD
SAINT LOUIS MO
63141-6715
US

IV. Provider business mailing address

745 N NEW BALLAS RD
SAINT LOUIS MO
63141-6715
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-7423
  • Fax: 314-567-7562
Mailing address:
  • Phone: 314-567-7423
  • Fax: 314-567-7562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL L HARRIS
Title or Position: PRESIDENT
Credential: ABOC
Phone: 314-567-7423