Provider Demographics
NPI:1417168469
Name:GALLAGHER EYE CARE OF HOLTON
Entity Type:Organization
Organization Name:GALLAGHER EYE CARE OF HOLTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:COFFEE
Authorized Official - Last Name:GALLAGHER
Authorized Official - Suffix:
Authorized Official - Credentials:OD FAAO
Authorized Official - Phone:785-364-5036
Mailing Address - Street 1:121 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLTON
Mailing Address - State:KS
Mailing Address - Zip Code:66436-1701
Mailing Address - Country:US
Mailing Address - Phone:785-364-5000
Mailing Address - Fax:785-364-5473
Practice Address - Street 1:121 W 4TH ST
Practice Address - Street 2:
Practice Address - City:HOLTON
Practice Address - State:KS
Practice Address - Zip Code:66436-1701
Practice Address - Country:US
Practice Address - Phone:785-364-5000
Practice Address - Fax:785-364-5473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS1648152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS5606570001OtherNORIDIAN DMERC
KS5606570001OtherNORIDIAN DMERC