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General NPI Number Information
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NPI Number | 1396854790
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Entity Type | Organization
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Legal Business Name | VISIONHEALTH EYE CENTER
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Dates
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Enumeration Date | 08/30/2006
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Last Update Date | 02/06/2009
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Provider Practice Location Address
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Address Line | 612 E ELM ST
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City | REPUBLIC
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State | MO
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Zip | 65738-1552
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Country | US
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Telephone | 417-732-5575
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Fax |
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Provider Business Mailing Address
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Address Line | 612 E ELM ST
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City | REPUBLIC
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State | MO
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Zip | 65738-1552
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Country | US
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Telephone | 417-732-5575
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER OF LLC
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Name | DR. JUSTIN L HART
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Credential | O.D.
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Telephone | 417-732-5575
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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 | 2006018212
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License Number State | MO
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