MEDICARE: CLARKSON EYECARE CENTER, INC

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

General Provider Information

NPI Number	:	1710925698
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLARKSON EYECARE CENTER, INC

Provider Business Mailing Address
First Line	:	40 E NORTH ST
Second Line	:
City	:	EUREKA
State	:	MO
Zip	:	63025
Country	:	US
Telephone Number	:	636-200-4393
Fax Number	:	636-938-2650

Provider Business Practice Location Address
First Line	:	194 CLARKSON RD
Second Line	:
City	:	ELLISVILLE
State	:	MO
Zip	:	63011-2244
Country	:	US
Telephone Number	:	636-227-2020
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF CENTRAL OPERATIONS
Name	:	KRIS CALDWELL
Credential	:
Telephone Number	:	636-200-4393

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	11/21/2007

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