MEDICARE: PEC SOUTH COUNTY 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	152WC0802X	Corneal and Contact Management Optometrist

General Provider Information

NPI Number	:	1295371946
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEC SOUTH COUNTY LLC

Provider Business Mailing Address
First Line	:	4111 N ILLINOIS ST
Second Line	:
City	:	SWANSEA
State	:	IL
Zip	:	62226-7609
Country	:	US
Telephone Number	:	618-234-3053
Fax Number	:

Provider Business Practice Location Address
First Line	:	4412 TELEGRAPH RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63129-3316
Country	:	US
Telephone Number	:	618-234-3053
Fax Number	:

Authorized Official
Title or Position	:	OPTOMETRIST/OWNER
Name	:	DIRK MASSIE
Credential	:	OD
Telephone Number	:	618-234-3053

Provider Enumeration Date	:	11/18/2019
Last Update Date	:	11/18/2019

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