Provider Demographics
NPI:1518019199
Name:PROFESSIONAL EYECARE - FOUNTAINS INC
Entity Type:Organization
Organization Name:PROFESSIONAL EYECARE - FOUNTAINS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGED CARE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:LORRAINE
Authorized Official - Last Name:ROYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-696-0092
Mailing Address - Street 1:9216 METCALF AVE # 9216A
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-1476
Mailing Address - Country:US
Mailing Address - Phone:913-387-4134
Mailing Address - Fax:913-652-6800
Practice Address - Street 1:9216 METCALF AVE # 9216A
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-1476
Practice Address - Country:US
Practice Address - Phone:913-387-4134
Practice Address - Fax:913-652-6800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1308152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS6393560001Medicare NSC