1336184993 NPI number — EYE SURGERY CENTER OF WICHITA, LLC

Table of content: (NPI 1336184993)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336184993 NPI number — EYE SURGERY CENTER OF WICHITA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE SURGERY CENTER OF WICHITA, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
TEAM VISION SURGERY CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336184993
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1A BURTON HILLS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37215-6187
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-665-1283
Provider Business Mailing Address Fax Number:
615-234-1720

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6100 E CENTRAL AVE STE 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67208-4237
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-681-2020
Provider Business Practice Location Address Fax Number:
316-684-4939
Provider Enumeration Date:
06/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SNODGRASS
Authorized Official First Name:
JEFFRREY
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
615-665-1283

Provider Taxonomy Codes

  • Taxonomy code: 261QS0132X , with the licence number:  SO87004 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1181 . This is a "PPK & PHS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 490004218 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 100343550A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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