Provider Demographics
NPI:1578783700
Name:MATTAX NEU PRATER EYE CENTER, INC.
Entity Type:Organization
Organization Name:MATTAX NEU PRATER EYE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:MATTAX
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:417-886-3937
Mailing Address - Street 1:1265 E PRIMROSE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4278
Mailing Address - Country:US
Mailing Address - Phone:417-886-3937
Mailing Address - Fax:417-886-1285
Practice Address - Street 1:430 N JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-2742
Practice Address - Country:US
Practice Address - Phone:417-588-2400
Practice Address - Fax:417-588-2059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO325886208Medicaid
MO1257300002Medicare ID - Type UnspecifiedREGION D DMERC-MEDICARE