Provider Demographics
NPI:1063758878
Name:PIERCE VISION SPECIALISTS, LLC
Entity type:Organization
Organization Name:PIERCE VISION SPECIALISTS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KALLMBAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-887-7151
Mailing Address - Street 1:3626 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-6069
Mailing Address - Country:US
Mailing Address - Phone:417-887-7151
Mailing Address - Fax:417-887-7153
Practice Address - Street 1:3626 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-6069
Practice Address - Country:US
Practice Address - Phone:417-887-7151
Practice Address - Fax:417-887-7153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-26
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1063758878Medicaid