Provider Demographics
NPI:1053702381
Name:CRESCENT EYECARE
Entity type:Organization
Organization Name:CRESCENT EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TAREQ
Authorized Official - Middle Name:ISSAM
Authorized Official - Last Name:NABHAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:314-479-9305
Mailing Address - Street 1:12110 SAINT CHARLES ROCK RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2601
Mailing Address - Country:US
Mailing Address - Phone:314-291-3700
Mailing Address - Fax:314-291-3708
Practice Address - Street 1:12110 SAINT CHARLES ROCK RD
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2601
Practice Address - Country:US
Practice Address - Phone:314-291-3700
Practice Address - Fax:314-291-3708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012020857152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty