Healthcare Provider Details

I. General information

NPI: 1992944979
Provider Name (Legal Business Name): EYEGLASS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2009
Last Update Date: 02/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 MISSOURI AVE STE 22
SAINT ROBERT MO
65584-4680
US

IV. Provider business mailing address

690 MISSOURI AVE STE 22
SAINT ROBERT MO
65584-4680
US

V. Phone/Fax

Practice location:
  • Phone: 573-336-4670
  • Fax: 573-336-5968
Mailing address:
  • Phone: 573-336-4670
  • Fax: 573-336-5968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberTO3060
License Number StateMO

VIII. Authorized Official

Name: MRS. NANCY EILEEN SUTTON
Title or Position: FRONT OFFICE MANAGER
Credential: ABOC
Phone: 573-336-4670