Healthcare Provider Details

I. General information

NPI: 1043829088
Provider Name (Legal Business Name): PEC WARRENTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

277 W VETERANS MEMORIAL PKWY
WARRENTON MO
63383-1067
US

IV. Provider business mailing address

277 W VETERANS MEMORIAL PKWY
WARRENTON MO
63383-1067
US

V. Phone/Fax

Practice location:
  • Phone: 636-456-2020
  • Fax: 636-456-3411
Mailing address:
  • Phone: 636-456-2020
  • Fax: 636-456-3411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: PAM HARK
Title or Position: BILLING
Credential:
Phone: 618-234-3053