Healthcare Provider Details

I. General information

NPI: 1730596248
Provider Name (Legal Business Name): EYECARE SPECIALTIES OF MISSOURI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2014
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E RUSSELL AVE SUITE A
WARRENSBURG MO
64093-9605
US

IV. Provider business mailing address

601 E RUSSELL AVE SUITE A
WARRENSBURG MO
64093-9605
US

V. Phone/Fax

Practice location:
  • Phone: 660-747-2020
  • Fax: 660-747-0574
Mailing address:
  • Phone: 660-747-2020
  • Fax: 660-747-0574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MISS NICOLE E GAITHER
Title or Position: INSURANCE DEPT.
Credential:
Phone: 660-885-7116