Provider Demographics
NPI:1821101189
Name:COLLINS EYE CLINIC, L.L.C.
Entity Type:Organization
Organization Name:COLLINS EYE CLINIC, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEANN
Authorized Official - Middle Name:R
Authorized Official - Last Name:EDELSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-869-3200
Mailing Address - Street 1:1342 E PRIMROSE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4279
Mailing Address - Country:US
Mailing Address - Phone:417-869-3200
Mailing Address - Fax:417-869-3212
Practice Address - Street 1:1342 E PRIMROSE ST
Practice Address - Street 2:SUITE B
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4279
Practice Address - Country:US
Practice Address - Phone:417-869-3200
Practice Address - Fax:417-869-3212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114662207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203814702Medicaid
AR169437002Medicaid
MO203814702Medicaid
MOG34643Medicare UPIN
MO203814702Medicaid
MO6245790001Medicare NSC