Provider Demographics
NPI:1730282021
Name:HARLEY'S CYCLE SUPPLY
Entity Type:Organization
Organization Name:HARLEY'S CYCLE SUPPLY
Other - Org Name:A & B OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:UPDEGRAFF
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:620-663-4411
Mailing Address - Street 1:1500 E 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67501-3701
Mailing Address - Country:US
Mailing Address - Phone:620-663-4411
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST 11TH AVE
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502
Practice Address - Country:US
Practice Address - Phone:620-663-4411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS151179156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS117550OtherBLUECROSSBLUESHIELD OF KS