Healthcare Provider Details

I. General information

NPI: 1174561773
Provider Name (Legal Business Name): KEVIN K.E. CARL, O.D. DBA EYE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 W NEWTON ST
VERSAILLES MO
65084-1068
US

IV. Provider business mailing address

506 W NEWTON ST
VERSAILLES MO
65084-1068
US

V. Phone/Fax

Practice location:
  • Phone: 573-378-6646
  • Fax: 573-378-6864
Mailing address:
  • Phone: 573-378-6646
  • Fax: 573-378-6864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02658
License Number StateMO

VIII. Authorized Official

Name: DR. KEVIN K CARL
Title or Position: OWNER
Credential: O.D.
Phone: 573-378-6646