MEDICARE: PIERCE VISION SPECIALISTS, LLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063758878
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PIERCE VISION SPECIALISTS, LLC

Provider Business Mailing Address
First Line	:	3626 SOUTH AVE
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65807-6069
Country	:	US
Telephone Number	:	417-887-7151
Fax Number	:	417-887-7153

Provider Business Practice Location Address
First Line	:	3626 SOUTH AVE
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65807-6069
Country	:	US
Telephone Number	:	417-887-7151
Fax Number	:	417-887-7153

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	ANGELA MARIE KALLMBAH
Credential	:
Telephone Number	:	417-887-7151

Provider Enumeration Date	:	12/26/2012
Last Update Date	:	09/01/2020

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