Provider Demographics
NPI:1043495062
Name:T M SWINGER & D V MCKILLIP, PTR
Entity type:Organization
Organization Name:T M SWINGER & D V MCKILLIP, PTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-379-5235
Mailing Address - Street 1:306 KING AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63873-1441
Mailing Address - Country:US
Mailing Address - Phone:573-379-5235
Mailing Address - Fax:
Practice Address - Street 1:306 KING AVE
Practice Address - Street 2:
Practice Address - City:PORTAGEVILLE
Practice Address - State:MO
Practice Address - Zip Code:63873-1441
Practice Address - Country:US
Practice Address - Phone:573-379-5235
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02167152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO310150404Medicaid
MO0279400002OtherNSC MEDICARE
MO410027250OtherRAILROAD MEDICARE
MO0279400002Medicare NSC
MO990001675Medicare PIN