MEDICARE: NU-CROWN, 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	14068	OTHER		SPECTERA

General Provider Information

NPI Number	:	1275691354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NU-CROWN, LLC

Provider Business Mailing Address
First Line	:	211 E BROADWAY
Second Line	:
City	:	ALTON
State	:	IL
Zip	:	62002-6220
Country	:	US
Telephone Number	:	618-462-9818
Fax Number	:	800-432-6004

Provider Business Practice Location Address
First Line	:	5694 TELEGRAPH PLAZA
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63129-4243
Country	:	US
Telephone Number	:	314-846-4222
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. CHARLES D. MATTHEWS
Credential	:
Telephone Number	:	618-462-9818

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	04/21/2017

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