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General NPI Number Information
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NPI Number | 1891820122
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Entity Type | Organization
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Legal Business Name | EYECARE PROFESSIONALS, INC
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Dates
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Enumeration Date | 02/23/2007
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Last Update Date | 12/11/2007
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Provider Practice Location Address
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Address Line | 111 N MAIN ST
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City | NEVADA
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State | MO
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Zip | 64772-2330
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Country | US
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Telephone | 417-667-3076
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Fax | 417-667-8690
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Provider Business Mailing Address
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Address Line | 111 N MAIN ST
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City | NEVADA
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State | MO
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Zip | 64772-2330
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Country | US
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Telephone | 417-667-3076
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Fax | 417-667-8690
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Authorized Official
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Title or Position | PRES OF CORP
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Name | DELTON L FAST
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Credential | OD
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Telephone | 417-667-3076
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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 |
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License Number State |
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