Provider Demographics
NPI:1932330529
Name:EYE CLINIC LLC
Entity Type:Organization
Organization Name:EYE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:KE
Authorized Official - Last Name:CARL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:660-826-2642
Mailing Address - Street 1:1200 WINCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-2467
Mailing Address - Country:US
Mailing Address - Phone:660-826-2642
Mailing Address - Fax:660-826-6748
Practice Address - Street 1:1200 WINCHESTER DR
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2467
Practice Address - Country:US
Practice Address - Phone:660-826-2642
Practice Address - Fax:660-826-6748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-31
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02658152W00000X
MO2004017484152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA2061Medicare UPIN
MO6375900002Medicare NSC
MODP6465Medicare PIN