Provider Demographics
NPI:1568513836
Name:PROFESSIONAL EYECARE METRO NORTH INC
Entity Type:Organization
Organization Name:PROFESSIONAL EYECARE METRO NORTH 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 1:400 NW BARRY RD STE 291A
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64155-2771
Mailing Address - Country:US
Mailing Address - Phone:816-436-4766
Mailing Address - Fax:816-436-6471
Practice Address - Street 1:400 NW BARRY RD STE 291A
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64155-2771
Practice Address - Country:US
Practice Address - Phone:816-436-4766
Practice Address - Fax:816-436-6471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2880152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO6389490001Medicare NSC