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General NPI Number Information
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NPI Number | 1578969960
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Entity Type | Organization
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Legal Business Name | BOLIVAR VISION, LLC
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Dates
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Enumeration Date | 11/12/2014
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Last Update Date | 12/21/2023
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Provider Practice Location Address
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Address Line | 680 E ALDRICH ROAD
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City | BOLIVAR
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State | MO
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Zip | 65613
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Country | US
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Telephone | 417-777-9000
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Fax | 417-777-9003
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Provider Business Mailing Address
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Address Line | 325 S MAIN AVE
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City | BOLIVAR
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State | MO
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Zip | 65613-2052
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Country | US
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Telephone | 417-777-9000
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Fax | 417-777-9003
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Authorized Official
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Title or Position | OPTOMETRIST/OWNER
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Name | DR. LAURA BETH MONTGOMERY
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Credential | O.D.
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Telephone | 417-777-9000
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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 | 20060182040
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License Number State | MO
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