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General NPI Number Information
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NPI Number | 1174806301
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Entity Type | Organization
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Legal Business Name | WILDWOOD VISION SPECIALISTS LLC
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Dates
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Enumeration Date | 09/23/2011
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Last Update Date | 06/24/2013
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Provider Practice Location Address
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Address Line | 2751 FOUNTAIN PL SUITE 2
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City | WILDWOOD
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State | MO
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Zip | 63040-1202
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Country | US
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Telephone | 314-583-1548
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Fax | 636-273-3918
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Provider Business Mailing Address
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Address Line | 2751 FOUNTAIN PL SUITE 2
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City | WILDWOOD
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State | MO
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Zip | 63040-1202
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Country | US
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Telephone | 314-583-1548
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Fax | 636-273-3918
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Authorized Official
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Title or Position | MANAGING OPTOMETRIST
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Name | DR. CHRISTINE MARIE HAYES
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Credential | O.D.
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Telephone | 314-583-1548
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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 | 2011018556
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2011018560
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License Number State | MO
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