MEDICARE: CRESCENT EYECARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2012020857	MO

General Provider Information

NPI Number	:	1053702381
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRESCENT EYECARE

Provider Business Mailing Address
First Line	:	12110 SAINT CHARLES ROCK RD
Second Line	:
City	:	BRIDGETON
State	:	MO
Zip	:	63044-2601
Country	:	US
Telephone Number	:	314-291-3700
Fax Number	:	314-291-3708

Provider Business Practice Location Address
First Line	:	12110 SAINT CHARLES ROCK RD
Second Line	:
City	:	BRIDGETON
State	:	MO
Zip	:	63044-2601
Country	:	US
Telephone Number	:	314-291-3700
Fax Number	:	314-291-3708

Authorized Official
Title or Position	:	OWNER/OPTOMETRIST
Name	:	DR. TAREQ ISSAM NABHAN
Credential	:	O.D.
Telephone Number	:	314-479-9305

Provider Enumeration Date	:	02/09/2015
Last Update Date	:	02/09/2015

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