1851454151 NPI number — DOWNTOWN CLINIC OF OPTOMETRY, INC

Table of content: (NPI 1851454151)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851454151 NPI number — DOWNTOWN CLINIC OF OPTOMETRY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOWNTOWN CLINIC OF 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:
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:
1851454151
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
720 OLIVE ST
Provider Second Line Business Mailing Address:
SUITE 420
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63101-2338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-231-0581
Provider Business Mailing Address Fax Number:
314-231-2690

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
720 OLIVE ST
Provider Second Line Business Practice Location Address:
SUITE 420
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63101-2338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-231-0581
Provider Business Practice Location Address Fax Number:
314-231-2690
Provider Enumeration Date:
12/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MIYAMOTO
Authorized Official First Name:
MORIO
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
314-231-0581

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  T2320 , 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: 0791940001 . This is a "MEDICARE REGIOND/DMERC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 310753819 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000007673 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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