1699806919 NPI number — EYECARE MANAGEMENT LLC

Table of content: (NPI 1699806919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699806919 NPI number — EYECARE MANAGEMENT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYECARE MANAGEMENT LLC
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:
1699806919
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 W LINCOLN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62220-2019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-277-1130
Provider Business Mailing Address Fax Number:
618-937-8403

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12818 TESSON FERRY RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63128-2945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-843-4044
Provider Business Practice Location Address Fax Number:
314-843-2941
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CUMMINS
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
BILLING DEPARTMENT MGR
Authorized Official Telephone Number:
618-277-1130

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , 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)

  • Identifier: 202559308 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 317834034 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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