Provider Demographics
NPI:1831228071
Name:CHABOT COMMUNITY EYE CARE PC
Entity type:Organization
Organization Name:CHABOT COMMUNITY EYE CARE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:CHABOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-522-8773
Mailing Address - Street 1:248 S FLORISSANT RD
Mailing Address - Street 2:
Mailing Address - City:FERGUSON
Mailing Address - State:MO
Mailing Address - Zip Code:63135-2736
Mailing Address - Country:US
Mailing Address - Phone:314-522-8773
Mailing Address - Fax:
Practice Address - Street 1:248 S FLORISSANT RD
Practice Address - Street 2:
Practice Address - City:FERGUSON
Practice Address - State:MO
Practice Address - Zip Code:63135-2736
Practice Address - Country:US
Practice Address - Phone:314-522-8773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO509295507Medicaid
IL4444460001Medicare NSC
ILDE4644Medicare PIN
MO000014278Medicare PIN
MO4444460001Medicare NSC
IL210126Medicare PIN
MO509295507Medicaid
MO000014033Medicare PIN