Provider Demographics
NPI:1013143957
Name:ADVANCED EYE CARE OF WINFIELD LLC
Entity Type:Organization
Organization Name:ADVANCED EYE CARE OF WINFIELD LLC
Other - Org Name:ADVANCED EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:573-324-3131
Mailing Address - Street 1:43 ELLIS AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-1151
Mailing Address - Country:US
Mailing Address - Phone:636-528-4144
Mailing Address - Fax:
Practice Address - Street 1:43 ELLIS AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1151
Practice Address - Country:US
Practice Address - Phone:636-528-4144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED EYE CARE OF WINFIELD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-05
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03408152W00000X
MO2008017063152W00000X
MO2007018394152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1811159882Medicaid
MO1265473383Medicaid
MO1609305580Medicaid