Provider Demographics
NPI:1043255243
Name:MCCAULLEY OPTOMETRIC PA
Entity Type:Organization
Organization Name:MCCAULLEY OPTOMETRIC PA
Other - Org Name:THE 10TH STREET EYECARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCCAULLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:620-792-2020
Mailing Address - Street 1:2601 10TH ST
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-4253
Mailing Address - Country:US
Mailing Address - Phone:620-792-2020
Mailing Address - Fax:620-792-2583
Practice Address - Street 1:2601 10TH ST
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-4253
Practice Address - Country:US
Practice Address - Phone:620-792-2020
Practice Address - Fax:620-792-2583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1198-3152W00000X
KS1692152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100213630AMedicaid
KS005344OtherBCBS GROUP NUMBER
KS020075001OtherCIGNA MC GROUP NUMBER
KS005344Medicare PIN
KS0200750001Medicare NSC