Provider Demographics
NPI:1467493502
Name:LAIS, REBECCA JANE (OPT)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:JANE
Last Name:LAIS
Suffix:
Gender:F
Credentials:OPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2632 CUNNINGHAM AVE
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1542
Mailing Address - Country:US
Mailing Address - Phone:417-623-3448
Mailing Address - Fax:
Practice Address - Street 1:2632 CUNNINGHAM AVE
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1542
Practice Address - Country:US
Practice Address - Phone:417-623-3448
Practice Address - Fax:417-623-3448
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MON/A156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO320412703Medicaid
MO320412703Medicaid
MOT42610Medicare UPIN