1790888634 NPI number — MATTAX NEU PRATER EYE CENTER 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 1790888634 NPI number — MATTAX NEU PRATER EYE CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MATTAX NEU PRATER EYE CENTER 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:
1790888634
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1265 E PRIMROSE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65804-4278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-886-3937
Provider Business Mailing Address Fax Number:
417-886-1285

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2170 E CLEVELAND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONETT
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65708-6134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-886-3937
Provider Business Practice Location Address Fax Number:
417-886-1285
Provider Enumeration Date:
09/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MATTAX
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
417-886-3937

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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