Healthcare Provider Details

I. General information

NPI: 1609041383
Provider Name (Legal Business Name): NU-CROWN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 05/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 JEFFERSON ST STE 110
WASHINGTON MO
63090-6449
US

IV. Provider business mailing address

211 E BROADWAY
ALTON IL
62002-6220
US

V. Phone/Fax

Practice location:
  • Phone: 636-239-1650
  • Fax: 636-239-9005
Mailing address:
  • Phone: 618-462-9818
  • Fax: 314-741-4947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2000158832
License Number StateMO

VIII. Authorized Official

Name: MR. CHARLES D. MATTHEWS
Title or Position: PRESIDENT
Credential:
Phone: 618-462-9818