Provider Demographics
NPI:1871071456
Name:J.E.A. WEGENER INC
Entity type:Organization
Organization Name:J.E.A. WEGENER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:WEGENER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:816-896-0225
Mailing Address - Street 1:42 WESTWOODS DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-3519
Mailing Address - Country:US
Mailing Address - Phone:816-896-0225
Mailing Address - Fax:
Practice Address - Street 1:42 WESTWOODS DR
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068
Practice Address - Country:US
Practice Address - Phone:816-781-0500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-05
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012027842152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1154669968Medicaid