Provider Demographics
NPI:1336327204
Name:MISSOURI LASER, LLC
Entity Type:Organization
Organization Name:MISSOURI LASER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GLEASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-547-4130
Mailing Address - Street 1:6339 E SPEEDWAY BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-1147
Mailing Address - Country:US
Mailing Address - Phone:520-547-4130
Mailing Address - Fax:520-258-0304
Practice Address - Street 1:334 E KEARNEY ST
Practice Address - Street 2:PMB 221
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-3018
Practice Address - Country:US
Practice Address - Phone:520-547-4130
Practice Address - Fax:520-258-0304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical