Provider Demographics
NPI:1316278013
Name:OSAGE BEACH FAMILY EYECARE INC.
Entity type:Organization
Organization Name:OSAGE BEACH FAMILY EYECARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:EVELAND
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:573-552-8569
Mailing Address - Street 1:5962 HIGHWAY 54
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3338
Mailing Address - Country:US
Mailing Address - Phone:573-552-8569
Mailing Address - Fax:
Practice Address - Street 1:5962 HIGHWAY 54
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3338
Practice Address - Country:US
Practice Address - Phone:573-552-8569
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03438152WC0802X, 152WL0500X, 152WP0200X, 152WX0102X, 152W00000X
T03438152WS0006X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO6499590001Medicare NSC
MOMA2410Medicare PIN
MODQ5421Medicare PIN