MEDICARE: MARVIN OPTOMETRY-MISSOURI, P.C.

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	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1154931517
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARVIN OPTOMETRY-MISSOURI, P.C.

Provider Business Mailing Address
First Line	:	1405 S HANLEY RD STE B
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63144-2902
Country	:	US
Telephone Number	:	314-652-3922
Fax Number	:	314-207-6601

Provider Business Practice Location Address
First Line	:	1405 S HANLEY RD STE B
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63144-2902
Country	:	US
Telephone Number	:	314-703-9048
Fax Number	:

Authorized Official
Title or Position	:	OPTOMETRIST/OWNER
Name	:	DR. ASHLEY MARVIN
Credential	:	OD
Telephone Number	:	618-514-5268

Provider Enumeration Date	:	07/31/2020
Last Update Date	:	01/06/2021

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