Basic Information
Provider Information | |||||||||
NPI: | 1912065137 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NU-CROWN, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CROWN OTPICAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 211 E BROADWAY | ||||||||
Address2: |   | ||||||||
City: | ALTON | ||||||||
State: | IL | ||||||||
PostalCode: | 620026220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6184629818 | ||||||||
FaxNumber: | 8004326004 | ||||||||
Practice Location | |||||||||
Address1: | 569 MID RIVERS MALL DR | ||||||||
Address2: |   | ||||||||
City: | SAINT PETERS | ||||||||
State: | MO | ||||||||
PostalCode: | 633762152 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6369702020 | ||||||||
FaxNumber: | 8004326004 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/04/2006 | ||||||||
LastUpdateDate: | 04/21/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MATTHEWS | ||||||||
AuthorizedOfficialFirstName: | CHARLES | ||||||||
AuthorizedOfficialMiddleName: | D. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6184629818 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X |   | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 14062 | 01 |   | SPECTERA | OTHER |