Provider Demographics
NPI:1457763658
Name:AMY J. KNICKERBOCKER, LLC
Entity Type:Organization
Organization Name:AMY J. KNICKERBOCKER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:JOANNE
Authorized Official - Last Name:KNICKERBOCKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:573-406-5276
Mailing Address - Street 1:3650 STARDUST DR
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-2480
Mailing Address - Country:US
Mailing Address - Phone:573-406-1503
Mailing Address - Fax:573-406-1057
Practice Address - Street 1:7 OAK RIDGE POND RD
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6539
Practice Address - Country:US
Practice Address - Phone:573-406-5276
Practice Address - Fax:573-406-1503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-22
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000143624152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty