Provider Demographics
NPI:1164475810
Name:CLARKSON EYECARE
Entity Type:Organization
Organization Name:CLARKSON EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER OF CENTRAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CALDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-200-4393
Mailing Address - Street 1:2404 TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1222
Mailing Address - Country:US
Mailing Address - Phone:636-458-8787
Mailing Address - Fax:
Practice Address - Street 1:2404 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1222
Practice Address - Country:US
Practice Address - Phone:636-458-8787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0360070019Medicare NSC