1992903660 NPI number — SOUTHWEST OZARK OPTOMETRIC PHYSICIANS INC

Table of content: (NPI 1992903660)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992903660 NPI number — SOUTHWEST OZARK OPTOMETRIC PHYSICIANS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST OZARK OPTOMETRIC PHYSICIANS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992903660
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
508 E PETTY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65785-9291
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-276-6254
Provider Business Mailing Address Fax Number:
417-667-2707

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2451 S SPRINGFIELD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOLIVAR
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65613-9123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-777-7662
Provider Business Practice Location Address Fax Number:
417-777-6917
Provider Enumeration Date:
07/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HOODKIRAR
Authorized Official First Name:
ALISON
Authorized Official Middle Name:
LEIGH
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
417-276-6254

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2003015541 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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