Provider Demographics
NPI:1942510334
Name:LOFTIN EYECARE, LLC
Entity Type:Organization
Organization Name:LOFTIN EYECARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOFTIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:573-881-7176
Mailing Address - Street 1:PO BOX 104795
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4795
Mailing Address - Country:US
Mailing Address - Phone:573-881-7176
Mailing Address - Fax:573-635-9024
Practice Address - Street 1:724 WEST STADIUM BOULEVARD
Practice Address - Street 2:# 029 WALMART VISION CENTER
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109
Practice Address - Country:US
Practice Address - Phone:573-635-9024
Practice Address - Fax:573-635-9031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-19
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03245152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT24045Medicare UPIN
MOMA3175Medicare PIN