Provider Demographics
NPI:1760450449
Name:POWELL, JIMMY LEE
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:LEE
Last Name:POWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:COFFEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67337-3300
Mailing Address - Country:US
Mailing Address - Phone:620-251-0050
Mailing Address - Fax:620-251-0050
Practice Address - Street 1:1411 W 4TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-3300
Practice Address - Country:US
Practice Address - Phone:620-251-0050
Practice Address - Fax:620-251-0050
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100095230AMedicaid
KSOP7674OtherBLUE CROSS & BLUE SHIELD
KS100095230AMedicaid
KSOP7674OtherBLUE CROSS & BLUE SHIELD