Full Name | |
---|---|
Type | Facility |
Speciality | Optometrist |
Location | 210 S Main, Red Bud, Illinois |
Accepts Medicare Assignments | Does not participate in Medicare Program. The facility may not accept medicare assignment. |
Identifier | Type | State | Issuer |
---|---|---|---|
1952595878 | NPI | - | NPPES |
036104178 | Medicaid | IL | |
046008176 | Medicaid | IL | |
0460085471 | Medicaid | IL | |
0460089501 | Medicaid | IL | |
203195 | Other | PTAN | |
0460069901 | Medicaid | IL | |
046006474 | Medicaid | IL | |
0460078192 | Medicaid | IL | |
0460089082 | Medicaid | IL | |
203193 | Other | PTAN | |
203194 | Other | PTAN |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
152W00000X | Optometrist | (Illinois) | Primary |
Mailing Address | Practice Location Address |
---|---|
15933 Clayton Rd Ste 201, Ballwin, MO 63011-2172 Ph: (636) 200-4393 | 210 S Main, Red Bud, IL 62278 Ph: (618) 635-3535 |