Provider Demographics
NPI:1467153601
Name:KANSAS CITY OPTICAL, LLC
Entity Type:Organization
Organization Name:KANSAS CITY OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:BROBERG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:913-717-9296
Mailing Address - Street 1:13803 W 82ND TER
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66215-4168
Mailing Address - Country:US
Mailing Address - Phone:913-717-9296
Mailing Address - Fax:816-817-3769
Practice Address - Street 1:4609 INDEPENDENCE AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64124-2927
Practice Address - Country:US
Practice Address - Phone:913-717-9296
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty