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General NPI Number Information
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NPI Number | 1164693677
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Entity Type | Organization
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Legal Business Name | ST PETERS VISION CENTER INC
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Dates
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Enumeration Date | 03/13/2008
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Last Update Date | 03/13/2008
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Provider Practice Location Address
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Address Line | 6664 MEXICO RD
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City | SAINT PETERS
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State | MO
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Zip | 63376-4131
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Country | US
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Telephone | 636-970-2929
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Fax | 636-279-9020
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Provider Business Mailing Address
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Address Line | 6664 MEXICO RD
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City | SAINT PETERS
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State | MO
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Zip | 63376-4131
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Country | US
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Telephone | 636-970-2929
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Fax | 636-279-9020
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JAMES LELAND JACOB
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Credential | O.D.
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Telephone | 636-970-2929
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | TO2230
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License Number State | MO
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