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General NPI Number Information
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NPI Number | 1821597592
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Entity Type | Organization
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Legal Business Name | INNOVATIVE EYE CARE SPECIALISTS, LLC
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Dates
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Enumeration Date | 02/07/2018
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Last Update Date | 07/23/2018
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Provider Practice Location Address
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Address Line | 10275 WATSON RD
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City | SAINT LOUIS
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State | MO
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Zip | 63127
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Country | US
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Telephone | 816-517-3599
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Fax |
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Provider Business Mailing Address
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Address Line | 10275 WATSON RD
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City | SAINT LOUIS
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State | MO
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Zip | 63127-1103
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Country | US
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Telephone | 314-962-9334
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ERIC JERDE
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Credential | OD
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Telephone | 314-962-9334
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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 | 2012018551
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License Number State | MO
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