Provider Demographics
NPI:1891294948
Name:LIGE, CORINNE LAURA (BCO)
Entity Type:Individual
Prefix:
First Name:CORINNE
Middle Name:LAURA
Last Name:LIGE
Suffix:
Gender:F
Credentials:BCO
Other - Prefix:
Other - First Name:CORINNE
Other - Middle Name:LAURA
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BCO
Mailing Address - Street 1:2821 N BALLAS RD STE C30
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2393
Mailing Address - Country:US
Mailing Address - Phone:314-567-7585
Mailing Address - Fax:314-567-7083
Practice Address - Street 1:2821 N BALLAS RD STE C30
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2393
Practice Address - Country:US
Practice Address - Phone:314-567-7585
Practice Address - Fax:314-567-7083
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO09-318-21156FX1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist