Provider Demographics
NPI:1578969960
Name:BOLIVAR VISION, LLC
Entity Type:Organization
Organization Name:BOLIVAR VISION, LLC
Other - Org Name:VISION SOURCE BOLIVAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:417-777-9000
Mailing Address - Street 1:325 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-2052
Mailing Address - Country:US
Mailing Address - Phone:417-777-9000
Mailing Address - Fax:417-777-9003
Practice Address - Street 1:680 E ALDRICH ROAD
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613
Practice Address - Country:US
Practice Address - Phone:417-777-9000
Practice Address - Fax:417-777-9003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-12
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20060182040152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty