Provider Demographics
NPI:1639290505
Name:GODSHALL QUALITY EYECARE
Entity Type:Organization
Organization Name:GODSHALL QUALITY EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:
Authorized Official - Last Name:GODSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:816-228-1414
Mailing Address - Street 1:2248 SW STATE ROUTE 7
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64014
Mailing Address - Country:US
Mailing Address - Phone:816-228-1414
Mailing Address - Fax:816-228-2376
Practice Address - Street 1:2248 SW STATE ROUTE 7
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014
Practice Address - Country:US
Practice Address - Phone:816-228-1414
Practice Address - Fax:816-228-2376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03377152W00000X
MO557156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO30156046OtherBLUE CROSS BLUE SHIELD
MO6137120001Medicare NSC