Provider Demographics
NPI:1396075875
Name:FENTON EYE CARE
Entity type:Organization
Organization Name:FENTON EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:REDING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-343-6664
Mailing Address - Street 1:622 GRAVOIS RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-4137
Mailing Address - Country:US
Mailing Address - Phone:636-343-6664
Mailing Address - Fax:
Practice Address - Street 1:622 GRAVOIS RD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-4137
Practice Address - Country:US
Practice Address - Phone:636-343-6664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-06
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTO2138152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT42601Medicare UPIN
MO0538360001Medicare NSC