Provider Demographics
NPI:1801981899
Name:SOUTH COUNTY EYE CARE
Entity type:Organization
Organization Name:SOUTH COUNTY EYE CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:POLK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-843-5800
Mailing Address - Street 1:13131 TESSON FERRRY RD #108
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128
Mailing Address - Country:US
Mailing Address - Phone:314-843-5800
Mailing Address - Fax:314-843-5290
Practice Address - Street 1:13131 TESSON FERRRY RD #108
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128
Practice Address - Country:US
Practice Address - Phone:314-843-5800
Practice Address - Fax:314-843-5290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR9N88305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203015219Medicaid
MOMDR9N88OtherMO LICENSE #
MOE81756Medicare UPIN
MO000094728Medicare PIN