Provider Demographics
NPI:1104924992
Name:CENTRAL MISSOURI VISION CENTER
Entity type:Organization
Organization Name:CENTRAL MISSOURI VISION CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MCENTIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-659-5560
Mailing Address - Street 1:1445 CHRISTY DR STE A
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-2853
Mailing Address - Country:US
Mailing Address - Phone:573-659-5560
Mailing Address - Fax:573-659-5561
Practice Address - Street 1:1445 CHRISTY DR STE A
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-2853
Practice Address - Country:US
Practice Address - Phone:573-659-5560
Practice Address - Fax:573-659-5561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1124050588OtherDR. THOMAS GREENE NPI
MO312199649Medicaid
MOT02652OtherSTATE LICENSE NUMBER
MO312199649Medicaid
MO5011970001Medicare NSC
MOT4810Medicare UPIN