Healthcare Provider Details

I. General information

NPI: 1487817193
Provider Name (Legal Business Name): LIGHTS PROSTHETIC EYES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 07/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1736 E SUNSHINE ST SUITE 404
SPRINGFIELD MO
65804-1343
US

IV. Provider business mailing address

1318 W CANDLETREE DR SUITE 3
PEORIA IL
61614-8508
US

V. Phone/Fax

Practice location:
  • Phone: 417-889-0988
  • Fax:
Mailing address:
  • Phone: 309-676-3663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number17065569
License Number StateMO

VIII. Authorized Official

Name: MR. RANDY L LIGHT
Title or Position: PRESIDENT
Credential: BCO
Phone: 309-676-3663