Provider Demographics
NPI:1396854790
Name:VISIONHEALTH EYE CENTER
Entity type:Organization
Organization Name:VISIONHEALTH EYE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER OF LLC
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:417-732-5575
Mailing Address - Street 1:612 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MO
Mailing Address - Zip Code:65738-1552
Mailing Address - Country:US
Mailing Address - Phone:417-732-5575
Mailing Address - Fax:
Practice Address - Street 1:612 E ELM ST
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:MO
Practice Address - Zip Code:65738-1552
Practice Address - Country:US
Practice Address - Phone:417-732-5575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006018212152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000014996Medicare PIN