1104305564 NPI number — PROFESSIONAL EYECARE MANAGEMENT INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104305564 NPI number — PROFESSIONAL EYECARE MANAGEMENT INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL EYECARE MANAGEMENT INC.
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:
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:
1104305564
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11121 W 95TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OVERLAND PARK
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66214-1824
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-838-3417
Provider Business Mailing Address Fax Number:
913-492-5217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3201 S IOWA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWRENCE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66046-5205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-383-3417
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/07/2018

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSEN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
402-540-0017

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1014-3 , 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)





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