Provider Demographics
NPI:1144368432
Name:FREDERICKTOWN VISION CENTER INC
Entity type:Organization
Organization Name:FREDERICKTOWN VISION CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:NEEDHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-783-3573
Mailing Address - Street 1:152 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:63645-1452
Mailing Address - Country:US
Mailing Address - Phone:573-783-5959
Mailing Address - Fax:573-783-5946
Practice Address - Street 1:152 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645-1452
Practice Address - Country:US
Practice Address - Phone:573-783-5959
Practice Address - Fax:573-783-5946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO323296400Medicaid
MO000012961Medicare ID - Type Unspecified
MO323296400Medicaid