| NPI | 1013194067 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CATHY LEE SHORT Credentialing Manager 618-462-9818 |
| Organization Subpart ? | No |
| Primary Taxonomy | 152W00000X Optometrist |
| Additional Taxonomies | 332H00000X Eyewear Supplier (Equipment, not the service) |
| Enumeration Date | 2008-01-22 |
| Last Update Date | 2021-01-20 |