MEDICARE: EYE CLINIC 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	2004017484	MO
2	152W00000X	Optometrist	T02658	MO

General Provider Information

NPI Number	:	1932330529
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE CLINIC LLC

Provider Business Mailing Address
First Line	:	1200 WINCHESTER DR
Second Line	:
City	:	SEDALIA
State	:	MO
Zip	:	65301-2467
Country	:	US
Telephone Number	:	660-826-2642
Fax Number	:	660-826-6748

Provider Business Practice Location Address
First Line	:	1200 WINCHESTER DR
Second Line	:
City	:	SEDALIA
State	:	MO
Zip	:	65301-2467
Country	:	US
Telephone Number	:	660-826-2642
Fax Number	:	660-826-6748

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. KEVIN K.E. CARL
Credential	:	O.D.
Telephone Number	:	660-826-2642

Provider Enumeration Date	:	07/31/2009
Last Update Date	:	01/18/2011

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Directions to “EYE CLINIC LLC ” Practice Location

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