Provider Demographics
NPI:1447950183
Name:PG OPTICAL LLC
Entity type:Organization
Organization Name:PG OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:573-426-6779
Mailing Address - Street 1:306 N BISHOP AVE STE B
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2953
Mailing Address - Country:US
Mailing Address - Phone:573-426-6779
Mailing Address - Fax:
Practice Address - Street 1:306 N BISHOP AVE STE B
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2953
Practice Address - Country:US
Practice Address - Phone:573-426-6779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-09
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty