Provider Demographics
NPI:1134500101
Name:DERBY EYECARE LLC
Entity Type:Organization
Organization Name:DERBY EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOGAN
Authorized Official - Middle Name:KALE
Authorized Official - Last Name:BANISTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:316-640-4180
Mailing Address - Street 1:1626 E MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-2076
Mailing Address - Country:US
Mailing Address - Phone:316-640-4180
Mailing Address - Fax:
Practice Address - Street 1:1626 E MADISON AVE
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-2076
Practice Address - Country:US
Practice Address - Phone:316-640-4180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-15
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1856152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty