Provider Demographics
NPI:1770659864
Name:VISION STREET EYE CARE LLC
Entity Type:Organization
Organization Name:VISION STREET EYE CARE LLC
Other - Org Name:SAGO AND STREET EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:T
Authorized Official - Last Name:STREET
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:573-756-3170
Mailing Address - Street 1:102 WESTMOUNT DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-2970
Mailing Address - Country:US
Mailing Address - Phone:573-756-3170
Mailing Address - Fax:573-756-0173
Practice Address - Street 1:102 WESTMOUNT DR.
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-0829
Practice Address - Country:US
Practice Address - Phone:573-756-3170
Practice Address - Fax:573-756-0173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02599152W00000X
MO2000160791152W00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000015268Medicare PIN
MO5896930001Medicare NSC