Provider Demographics
NPI:1053427435
Name:EYECARE SPECIALTIES OF MISSOURI LLC
Entity type:Organization
Organization Name:EYECARE SPECIALTIES OF MISSOURI LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DR/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:660-885-7116
Mailing Address - Street 1:601 E RUSSELL AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-9605
Mailing Address - Country:US
Mailing Address - Phone:660-747-2020
Mailing Address - Fax:660-747-0574
Practice Address - Street 1:1104 E OHIO ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-2458
Practice Address - Country:US
Practice Address - Phone:660-885-7116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO504891805Medicaid
MOMA5292OtherMEDICARE PTAN
MOK590000Medicare ID - Type Unspecified
MO504891805Medicaid