1073560108 NPI number — DR. NICOLE DYAN VERACHTERT O.D.

Table of content: DR. NICOLE DYAN VERACHTERT O.D. (NPI 1073560108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073560108 NPI number — DR. NICOLE DYAN VERACHTERT O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VERACHTERT
Provider First Name:
NICOLE
Provider Middle Name:
DYAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1073560108
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6420 NW FOREST CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PARKVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64152-3139
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-880-0242
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6325 LEWIS DR
Provider Second Line Business Practice Location Address:
SUITE 114
Provider Business Practice Location Address City Name:
PARKVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64152-3699
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-505-0100
Provider Business Practice Location Address Fax Number:
816-505-2301
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  T03469 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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