1326090267 NPI number — CLARKSON OPTOMETRY INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326090267 NPI number — CLARKSON OPTOMETRY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLARKSON 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:
1326090267
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 207158
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75320-7158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-200-4393
Provider Business Mailing Address Fax Number:
636-527-0766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 E NORTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUREKA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-200-4393
Provider Business Practice Location Address Fax Number:
636-938-2650
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOLT
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER OF CENTRAL OPERATIONS
Authorized Official Telephone Number:
636-200-4393

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: CE9167 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 502027709 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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