=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609957885
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOUNT VERNON EYECARE ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2006
-----------------------------------------------------
Last Update Date | 09/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 S HICKORY
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-466-7620
-----------------------------------------------------
Fax | 417-466-7620
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 603
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65712-0603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-466-7620
-----------------------------------------------------
Fax | 417-466-7622
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | TANYA BURDETT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 417-235-5250
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------