Provider Demographics
NPI:1730232455
Name:NU-CROWN, LLC
Entity type:Organization
Organization Name:NU-CROWN, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-462-9818
Mailing Address - Street 1:211 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6220
Mailing Address - Country:US
Mailing Address - Phone:618-462-9818
Mailing Address - Fax:800-432-6004
Practice Address - Street 1:1560 W US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1619
Practice Address - Country:US
Practice Address - Phone:618-397-6575
Practice Address - Fax:618-397-1182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO14067OtherSPECTERA
IL202112Medicare PIN
IL0471360022Medicare NSC