1295838381 NPI number — DRS DAVIS JORDAN & BOWLING OPTOMETRISTS PC

Table of content: (NPI 1295838381)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295838381 NPI number — DRS DAVIS JORDAN & BOWLING OPTOMETRISTS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DRS DAVIS JORDAN & BOWLING OPTOMETRISTS PC
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:
1295838381
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 JAMES EPPS ROAD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
BRANSON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65616-7203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-334-7291
Provider Business Mailing Address Fax Number:
417-334-6456

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14974 US HIGHWAY 160
Provider Second Line Business Practice Location Address:
UNIT 6
Provider Business Practice Location Address City Name:
FORSYTH
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65653-5365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-546-4464
Provider Business Practice Location Address Fax Number:
417-546-4559
Provider Enumeration Date:
09/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
RICK
Authorized Official Middle Name:
W
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
417-334-7291

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: 328163001 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 507305605 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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