Provider Demographics
NPI:1932371457
Name:LISA B DIBLER OD LLC
Entity Type:Organization
Organization Name:LISA B DIBLER OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:BERRY
Authorized Official - Last Name:DIBLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:636-527-8877
Mailing Address - Street 1:171 LAMP AND LANTERN VILLAGE
Mailing Address - Street 2:
Mailing Address - City:TOWN AND COUNTRY
Mailing Address - State:MO
Mailing Address - Zip Code:63017-8208
Mailing Address - Country:US
Mailing Address - Phone:636-527-8877
Mailing Address - Fax:636-527-8897
Practice Address - Street 1:171 LAMP AND LANTERN VILLAGE
Practice Address - Street 2:
Practice Address - City:TOWN AND COUNTRY
Practice Address - State:MO
Practice Address - Zip Code:63017-8208
Practice Address - Country:US
Practice Address - Phone:636-527-8877
Practice Address - Fax:636-527-8897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03159152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU44100Medicare UPIN