=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023247087
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDWEST VISION CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2009
-----------------------------------------------------
Last Update Date | 08/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6614 CLAYTON RD # 319
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63117-1602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-249-7446
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6614 CLAYTON RD # 319
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63117-1602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-249-7446
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. CHANTAL H JACQUES
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 314-249-7446
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2009016926
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------