Provider Demographics
NPI:1356638662
Name:MAYDEW THIBAULT OPTOMETRY LLC
Entity Type:Organization
Organization Name:MAYDEW THIBAULT OPTOMETRY LLC
Other - Org Name:KINGMAN EYE CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:DR
Authorized Official - Prefix:DR
Authorized Official - First Name:SETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:THIBAULT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:620-672-5934
Mailing Address - Street 1:104 WEST C AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:KS
Mailing Address - Zip Code:67068-1313
Mailing Address - Country:US
Mailing Address - Phone:620-532-3154
Mailing Address - Fax:620-532-5662
Practice Address - Street 1:104 WEST C AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:KS
Practice Address - Zip Code:67068-1313
Practice Address - Country:US
Practice Address - Phone:620-532-3154
Practice Address - Fax:620-532-5662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-07
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1696152W00000X
KS1017-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200732580AMedicaid
KS200732580AMedicaid
KS1306600003Medicare NSC