1114970779 NPI number — CLARKSON OPTOMETRY INC

Table of content: (NPI 1114970779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114970779 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:
6
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:
1114970779
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15933 CLAYTON RD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
BALLWIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63011-2172
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:
699 GRAVOIS BLUFFS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FENTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63026-7715
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:
636-305-1021
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WACHTER
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
CMO
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: 723835007 . This is a "DMERC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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