Healthcare Provider Details

I. General information

NPI: 1760463384
Provider Name (Legal Business Name): TERESA L STICE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 02/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 W WASHINGTON
VANDALIA MO
63382
US

IV. Provider business mailing address

20660 ACR 306
MEXICO MO
65265
US

V. Phone/Fax

Practice location:
  • Phone: 573-594-2525
  • Fax: 573-594-3611
Mailing address:
  • Phone: 573-581-8668
  • Fax: 573-581-8850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT03337
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: