Healthcare Provider Details

I. General information

NPI: 1639320278
Provider Name (Legal Business Name): EAU CLAIRE REFRACTIVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2008
Last Update Date: 10/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 KENNEY AVE
EAU CLAIRE WI
54701-6361
US

IV. Provider business mailing address

16305 SWINGLEY RIDGE RD STE.300
CHESTERFIELD MO
63017-1777
US

V. Phone/Fax

Practice location:
  • Phone: 715-838-2020
  • Fax:
Mailing address:
  • Phone: 636-534-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRIAN ANDREW
Title or Position: SECRETARY
Credential:
Phone: 636-534-2300