1770613721 NPI number — WAREN OPTOMETRY

Table of content: (NPI 1770613721)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770613721 NPI number — WAREN OPTOMETRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAREN OPTOMETRY
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:
6
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:
1770613721
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2121 N TYLER RD
Provider Second Line Business Mailing Address:
SUITE 302
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67212-4900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-729-8600
Provider Business Mailing Address Fax Number:
316-773-3160

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2121 N TYLER RD
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67212-4920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-729-8600
Provider Business Practice Location Address Fax Number:
316-773-3160
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WAREN
Authorized Official First Name:
J
Authorized Official Middle Name:
WESLEY
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
316-729-8600

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1389-3 , 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)

  • Identifier: 065095 . This is a "BLUE CROSS/BLUE SHIELD OF KANSAS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 1770613721 . This is a "GROUP NPI" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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