Provider Demographics
NPI:1629271622
Name:BONEBRAKE VISION & EYE CENTER LLC
Entity Type:Organization
Organization Name:BONEBRAKE VISION & EYE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:SKEFFINGTON
Authorized Official - Last Name:BONEBRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:816-279-5683
Mailing Address - Street 1:707 N 36TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2968
Mailing Address - Country:US
Mailing Address - Phone:816-279-5683
Mailing Address - Fax:
Practice Address - Street 1:707 N 36TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2968
Practice Address - Country:US
Practice Address - Phone:816-279-5683
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT0248152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA1238Medicare UPIN
MO0170970001Medicare NSC