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General NPI Number Information
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NPI Number | 1396781829
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Entity Type | Organization
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Legal Business Name | 20/20 OPTICAL, LLC
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Dates
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Enumeration Date | 06/22/2006
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Last Update Date | 12/01/2009
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Provider Practice Location Address
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Address Line | 2952 DOUGHERTY FERRY RD
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City | KIRKWOOD
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State | MO
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Zip | 63122-3366
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Country | US
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Telephone | 636-825-2625
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Fax |
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Provider Business Mailing Address
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Address Line | 329 CARR MANOR CT
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City | BALLWIN
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State | MO
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Zip | 63021-3304
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Country | US
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Telephone | 636-527-4097
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Fax |
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Authorized Official
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Title or Position | OPTOMETIST/OFFICE MANAGER
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Name | SAMEENA SULTANA KHAN
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Credential | O.D.
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Telephone | 636-825-2625
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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 | TO3449
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License Number State | MO
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