=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588754758
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY R SACHO OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2006
-----------------------------------------------------
Last Update Date | 01/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 108 S MAIN ST
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62236-2306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-281-4500
-----------------------------------------------------
Fax | 618-281-4595
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12386 TOPSFIELD CT
-----------------------------------------------------
City | CREVE COEUR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-628-9009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046006642
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | T02381
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------