Provider Demographics
NPI:1679818389
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:
Authorized Official - First Name:ABBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RONDEAU-NELSON
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 1:3417 NW MILL DR
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64015-3257
Practice Address - Country:US
Practice Address - Phone:816-229-3001
Practice Address - Fax:816-229-9459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1750548871Medicaid
MO1750548871Medicaid
MA1946002Medicare PIN