Provider Demographics
NPI:1487047536
Name:CARTHAGE VISION CLINIC LLC
Entity type:Organization
Organization Name:CARTHAGE VISION CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:GOETZINGER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:417-359-0600
Mailing Address - Street 1:2020 S GARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MO
Mailing Address - Zip Code:64836-3687
Mailing Address - Country:US
Mailing Address - Phone:417-359-0600
Mailing Address - Fax:417-359-0601
Practice Address - Street 1:2020 S GARRISON AVE
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MO
Practice Address - Zip Code:64836-3687
Practice Address - Country:US
Practice Address - Phone:417-359-0600
Practice Address - Fax:417-359-0601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-13
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03101152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO7473660001OtherDMERC NORIDIAN PTAN
MOMA5504OtherMEDICARE PTAN
MODV9359OtherRAILROAD MEDICARE PTAN