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General NPI Number Information
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NPI Number | 1992206213
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Entity Type | Organization
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Legal Business Name | FARMINGTON VISION CARE LLC
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Dates
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Enumeration Date | 02/22/2018
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Last Update Date | 02/22/2018
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Provider Practice Location Address
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Address Line | 110 E HARRISON ST
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City | FARMINGTON
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State | MO
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Zip | 63640
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Country | US
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Telephone | 573-756-5665
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Fax |
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Provider Business Mailing Address
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Address Line | 21530 HWY 32 STE A
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City | STE GENEVIEVE
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State | MO
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Zip | 63670-8813
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Country | US
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Telephone | 573-883-5665
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Fax | 573-883-5661
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Authorized Official
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Title or Position | OWNER/OPTOMETRIST
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Name | DR. CLINT MICHAEL WOLK
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Credential | OD
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Telephone | 573-883-5665
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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 | MO
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