Provider Demographics
NPI:1174947998
Name:EYEWEAR EXPRESS OF MISSOURI, LLC
Entity type:Organization
Organization Name:EYEWEAR EXPRESS OF MISSOURI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCCARTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-774-5004
Mailing Address - Street 1:320 ICHORD AVE
Mailing Address - Street 2:SUITE H
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-3600
Mailing Address - Country:US
Mailing Address - Phone:573-774-5004
Mailing Address - Fax:573-774-5004
Practice Address - Street 1:320 ICHORD AVE
Practice Address - Street 2:SUITE H
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-3600
Practice Address - Country:US
Practice Address - Phone:573-774-5004
Practice Address - Fax:573-774-5004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO21892466305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service