Provider Demographics
NPI:1720128846
Name:DESLOGE VISION CENTER INC
Entity type:Organization
Organization Name:DESLOGE VISION CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SPIKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-518-0001
Mailing Address - Street 1:1136 N DESLOGE DR STE C
Mailing Address - Street 2:
Mailing Address - City:DESLOGE
Mailing Address - State:MO
Mailing Address - Zip Code:63601-2900
Mailing Address - Country:US
Mailing Address - Phone:573-518-0001
Mailing Address - Fax:573-518-0081
Practice Address - Street 1:1136 N DESLOGE DR STE C
Practice Address - Street 2:
Practice Address - City:DESLOGE
Practice Address - State:MO
Practice Address - Zip Code:63601-2900
Practice Address - Country:US
Practice Address - Phone:573-518-0001
Practice Address - Fax:573-518-0081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1234610001Medicare NSC