Provider Demographics
NPI:1356687768
Name:LONG BAY VISION PARTNERS
Entity Type:Organization
Organization Name:LONG BAY VISION PARTNERS
Other - Org Name:THE EYE GALLERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:N
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-446-1600
Mailing Address - Street 1:3301 W BROADWAY BUSINESS PARK CT
Mailing Address - Street 2:SUITE E
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-0106
Mailing Address - Country:US
Mailing Address - Phone:573-446-1600
Mailing Address - Fax:
Practice Address - Street 1:3301 W BROADWAY BUSINESS PARK CT
Practice Address - Street 2:SUITE E
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-0106
Practice Address - Country:US
Practice Address - Phone:573-446-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-13
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03285152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU71110Medicare UPIN