1346492865 NPI number — BENNETT EYECARE MIDWEST, LLC

Table of content: (NPI 1346492865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346492865 NPI number — BENNETT EYECARE MIDWEST, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BENNETT EYECARE MIDWEST, 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:
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:
1346492865
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2441 NW PRAIRIE VIEW RD.
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
PLATTE CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64079-7608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-858-2522
Provider Business Mailing Address Fax Number:
816-858-2946

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6080 N OAK TRWY
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
GLADSTONE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64118-5100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-454-2020
Provider Business Practice Location Address Fax Number:
816-453-2659
Provider Enumeration Date:
10/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BEDNAR
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
816-454-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 505840207 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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