Basic Information
| Provider Information | |||||||||
| NPI: | 1023215571 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY CLINIC SPRINGFIELD COMMUNITIES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EYE SPECIALISTS-OPTICAL SHOP-ROLLA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1605 MARTIN SPRINGS DR | ||||||||
| Address2: | STE 240 | ||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654012982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294215 | ||||||||
| FaxNumber: | 4178294316 | ||||||||
| Practice Location | |||||||||
| Address1: | 1605 MARTIN SPRINGS DR | ||||||||
| Address2: | SUITE 240A | ||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654012931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734586310 | ||||||||
| FaxNumber: | 5734586791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2007 | ||||||||
| LastUpdateDate: | 12/08/2015 | ||||||||
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| AuthorizedOfficialLastName: | STANGELAND | ||||||||
| AuthorizedOfficialFirstName: | STUART | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4178203873 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | MO | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.