Provider Demographics
NPI:1043380652
Name:REGIONAL EYECARE ASSOCIATES INC
Entity Type:Organization
Organization Name:REGIONAL EYECARE ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OD VP
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MACKEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:636-561-3937
Mailing Address - Street 1:3013 WINGHAVEN BLVD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-3600
Mailing Address - Country:US
Mailing Address - Phone:636-561-3937
Mailing Address - Fax:636-561-4068
Practice Address - Street 1:3013 WINGHAVEN BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-3600
Practice Address - Country:US
Practice Address - Phone:636-561-3937
Practice Address - Fax:636-561-4068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03134152W00000X
MOT03118152W00000X
MO2003015589152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO5473270002Medicare NSC