=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336704394
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STRATO3 LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2019
-----------------------------------------------------
Last Update Date | 05/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14169 MANCHESTER RD STE C
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63011-4525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-395-0471
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14169 MANCHESTER RD STE C
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63011-4525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | JOHN WEBSTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 520-907-5879
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------