Basic Information
| Provider Information | |||||||||
| NPI: | 1427290493 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIGHT AND SUN EYEWORKS LLC | ||||||||
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| OtherOrganizationName: | CLARKSON EYE CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15933 CLAYTON RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BALLWIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630112172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504797379 | ||||||||
| FaxNumber: | 8504976219 | ||||||||
| Practice Location | |||||||||
| Address1: | 2256 W NINE MILE RD STE B | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325349471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 8504792021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2009 | ||||||||
| LastUpdateDate: | 06/12/2019 | ||||||||
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| AuthorizedOfficialLastName: | SALAS | ||||||||
| AuthorizedOfficialFirstName: | EDITH | ||||||||
| AuthorizedOfficialMiddleName: | VIVIANA | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 8504797379 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SIGHT AND SUN EYEWORKS LLC | ||||||||
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| AuthorizedOfficialCredential: | AMA, CPO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 001650400 | 05 | FL | MEDICAID | 97937 | 01 | FL | FLORIDA BLUE | OTHER |