Provider Demographics
NPI:1922268564
Name:DE SOTO EYE CARE LLC
Entity Type:Organization
Organization Name:DE SOTO EYE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:MC GUIRE
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:636-586-5406
Mailing Address - Street 1:126 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DE SOTO
Mailing Address - State:MO
Mailing Address - Zip Code:63020-2104
Mailing Address - Country:US
Mailing Address - Phone:636-586-5406
Mailing Address - Fax:636-586-1969
Practice Address - Street 1:126 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:MO
Practice Address - Zip Code:63020-2104
Practice Address - Country:US
Practice Address - Phone:636-586-5406
Practice Address - Fax:636-586-1969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03075152W00000X
MOT02872152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO315698803Medicaid
MO313299505Medicaid
MOU78412Medicare UPIN
MOU08346Medicare UPIN
MO315698803Medicaid