Provider Demographics
NPI:1053482711
Name:EYECARE SPECIALTIES OF MISSOURI LLC
Entity Type:Organization
Organization Name:EYECARE SPECIALTIES OF MISSOURI LLC
Other - Org Name:EYECARE SPECIALTIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:H
Authorized Official - Last Name:LIESEMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:660-826-6161
Mailing Address - Street 1:601 E RUSSELL AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-9605
Mailing Address - Country:US
Mailing Address - Phone:660-747-2020
Mailing Address - Fax:660-747-0574
Practice Address - Street 1:3403 W 10TH ST
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2112
Practice Address - Country:US
Practice Address - Phone:660-826-6161
Practice Address - Fax:660-826-8197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02629152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO312338908Medicaid
MO0000795Medicare PIN
MO312338908Medicaid