Basic Information
| Provider Information | |||||||||
| NPI: | 1457763658 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMY J. KNICKERBOCKER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3650 STARDUST DR | ||||||||
| Address2: | |||||||||
| City: | HANNIBAL | ||||||||
| State: | MO | ||||||||
| PostalCode: | 634012480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734061503 | ||||||||
| FaxNumber: | 5734061057 | ||||||||
| Practice Location | |||||||||
| Address1: | 7 OAK RIDGE POND RD | ||||||||
| Address2: | |||||||||
| City: | HANNIBAL | ||||||||
| State: | MO | ||||||||
| PostalCode: | 634016539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734065276 | ||||||||
| FaxNumber: | 5734061503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2014 | ||||||||
| LastUpdateDate: | 05/22/2014 | ||||||||
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| AuthorizedOfficialLastName: | KNICKERBOCKER | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | JOANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST | ||||||||
| AuthorizedOfficialTelephone: | 5734065276 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2000143624 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.