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General NPI Number Information
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NPI Number | 1366080632
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Entity Type | Organization
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Legal Business Name | OPTIMIZED EYECARE, LLC
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Dates
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Enumeration Date | 12/17/2019
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Last Update Date | 12/17/2019
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Provider Practice Location Address
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Address Line | 317 CLARKSON RD
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City | ELLISVILLE
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State | MO
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Zip | 63011-2271
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Country | US
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Telephone | 314-374-6831
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Fax |
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Provider Business Mailing Address
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Address Line | 15976 DOWNALL GREEN DR
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City | CHESTERFIELD
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State | MO
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Zip | 63017-7320
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Country | US
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Telephone | 314-374-6831
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MATTHEW KELLY
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Credential | OD
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Telephone | 314-374-6831
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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 |
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License Number State |
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