1699857912 NPI number — SUREVISION EYE CENTERS MIDWEST LLC

Table of content: (NPI 1699857912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699857912 NPI number — SUREVISION EYE CENTERS MIDWEST LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUREVISION EYE CENTERS MIDWEST 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:
1699857912
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
320 BROOKES DR
Provider Second Line Business Mailing Address:
SUITE 111
Provider Business Mailing Address City Name:
HAZELWOOD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63042-2736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-726-5669
Provider Business Mailing Address Fax Number:
314-726-5109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12101 WOODCREST EXECUTIVE DR STE 150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CREVE COEUR
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63141-5050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-921-2020
Provider Business Practice Location Address Fax Number:
314-863-9977
Provider Enumeration Date:
10/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MIANA
Authorized Official First Name:
SHELLEY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
314-726-5669

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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