1275710014 NPI number — OBERMARK OPTOMETRY, INC

Table of content: (NPI 1275710014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275710014 NPI number — OBERMARK OPTOMETRY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OBERMARK OPTOMETRY, 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:
1275710014
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 W MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63090-2154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-239-7144
Provider Business Mailing Address Fax Number:
636-239-6266

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63090-2154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-239-7144
Provider Business Practice Location Address Fax Number:
636-239-6266
Provider Enumeration Date:
01/23/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OBERMARK
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
MITCHELL
Authorized Official Title or Position:
OFFICER / MANAGER
Authorized Official Telephone Number:
636-239-7144

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 317927903 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4195 X 1285 . This is a "HEALTHCARE USA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".