Healthcare Provider Details

I. General information

NPI: 1669988242
Provider Name (Legal Business Name): PEC ST PETERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2017
Last Update Date: 12/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6764 MEXICO RD
SAINT PETERS MO
63376-1505
US

IV. Provider business mailing address

4111 N ILLINOIS ST
SWANSEA IL
62226-7609
US

V. Phone/Fax

Practice location:
  • Phone: 618-234-3053
  • Fax:
Mailing address:
  • Phone: 618-234-3053
  • Fax: 618-234-6331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. DIRK MASSIE
Title or Position: OWNER
Credential: OD
Phone: 618-234-3053