Provider Demographics
NPI:1548399561
Name:DES PERES EYE SURGERY CENTER, LLC
Entity type:Organization
Organization Name:DES PERES EYE SURGERY CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOFRON
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:314-686-4200
Mailing Address - Street 1:12990 MANCHESTER RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1860
Mailing Address - Country:US
Mailing Address - Phone:314-686-4200
Mailing Address - Fax:314-686-4217
Practice Address - Street 1:12990 MANCHESTER RD
Practice Address - Street 2:SUITE 103
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1860
Practice Address - Country:US
Practice Address - Phone:314-686-4200
Practice Address - Fax:314-686-4217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00461792OtherRAILROAD MEDICARE
MO1548399561Medicaid