=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417191305
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARKS OPTICAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2009
-----------------------------------------------------
Last Update Date | 06/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 W JEFFERSON ST
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64735-2061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-885-2800
-----------------------------------------------------
Fax | 660-885-5353
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 106 W JEFFERSON ST
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64735-2061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-885-2800
-----------------------------------------------------
Fax | 660-885-5353
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. LISA K PARKS
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 660-885-2800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | T02752
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------