Provider Demographics
NPI:1578598041
Name:BENNETT EYECARE MIDWEST LLC
Entity Type:Organization
Organization Name:BENNETT EYECARE MIDWEST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ABBIE
Authorized Official - Middle Name:N
Authorized Official - Last Name:RONDEAU
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:816-858-2522
Mailing Address - Street 1:2441 NW PRAIRIE VIEW RD
Mailing Address - Street 2:
Mailing Address - City:PLATTE CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64079-7627
Mailing Address - Country:US
Mailing Address - Phone:816-858-2522
Mailing Address - Fax:816-858-2946
Practice Address - Street 1:6080 N OAK TRFY
Practice Address - Street 2:SUITE 101
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64118
Practice Address - Country:US
Practice Address - Phone:816-454-2020
Practice Address - Fax:816-453-2659
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BENNETT EYECARE MIDWEST LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-12
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02633152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1407839756OtherNPI
MO2018024194OtherSTATE LICENSE
MO318693827Medicaid
MO1669455747OtherNPI
MO535840201Medicaid
MO316013606Medicaid
MO505840207Medicaid
1528041860OtherNPI
MO1811159361OtherNPI
MO312478241Medicaid
MO505840207Medicaid
MO4508490001Medicare NSC
MOU55449Medicare UPIN
MO318693827Medicaid
MO1669455747OtherNPI
MOL807658Medicare ID - Type Unspecified
MOL801994Medicare ID - Type Unspecified