Provider Demographics
NPI:1215028097
Name:NESTLEROAD AND ROBERTS, OPTOMETRISTS
Entity Type:Organization
Organization Name:NESTLEROAD AND ROBERTS, OPTOMETRISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURDETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-235-5250
Mailing Address - Street 1:PO BOX 351
Mailing Address - Street 2:
Mailing Address - City:MONETT
Mailing Address - State:MO
Mailing Address - Zip Code:65708-0351
Mailing Address - Country:US
Mailing Address - Phone:417-235-5250
Mailing Address - Fax:417-235-5259
Practice Address - Street 1:507 E CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:MONETT
Practice Address - State:MO
Practice Address - Zip Code:65708-1750
Practice Address - Country:US
Practice Address - Phone:417-235-5250
Practice Address - Fax:417-235-5259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO530163807Medicaid
MO1206460001Medicare NSC
MO530163807Medicaid