Healthcare Provider Details

I. General information

NPI: 1407410087
Provider Name (Legal Business Name): MISSOURI PHYSICIANS EYECARE GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 04/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 E BATTLEFIELD ST
SPRINGFIELD MO
65804-3701
US

IV. Provider business mailing address

3801 S CONGRESS AVE
PALM SPRINGS FL
33461-4140
US

V. Phone/Fax

Practice location:
  • Phone: 561-275-2020
  • Fax: 561-275-2030
Mailing address:
  • Phone: 561-275-2020
  • Fax: 561-275-2030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JACKIE BENNETT
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 561-612-4531