Provider Demographics
NPI:1891730388
Name:DANIEL BOONE, O.D.
Entity Type:Organization
Organization Name:DANIEL BOONE, O.D.
Other - Org Name:NIXA FAMILY EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:417-725-0000
Mailing Address - Street 1:107 VILLAGE CENTER ST
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-7824
Mailing Address - Country:US
Mailing Address - Phone:417-725-0000
Mailing Address - Fax:417-725-0002
Practice Address - Street 1:107 VILLAGE CENTER ST
Practice Address - Street 2:
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-7824
Practice Address - Country:US
Practice Address - Phone:417-725-0000
Practice Address - Fax:417-725-0002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03007152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO5075511202Medicaid
MO5075511202Medicaid
MO0807000001Medicare NSC