Provider Demographics
NPI:1821597592
Name:INNOVATIVE EYE CARE SPECIALISTS, LLC
Entity Type:Organization
Organization Name:INNOVATIVE EYE CARE SPECIALISTS, LLC
Other - Org Name:JERDE EYE SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:JERDE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:314-962-9334
Mailing Address - Street 1:10275 WATSON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1103
Mailing Address - Country:US
Mailing Address - Phone:314-962-9334
Mailing Address - Fax:
Practice Address - Street 1:10275 WATSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127
Practice Address - Country:US
Practice Address - Phone:816-517-3599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-07
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012018551152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty