Provider Demographics
NPI:1932330297
Name:INNOVATIVE EYECARE LLC
Entity Type:Organization
Organization Name:INNOVATIVE EYECARE LLC
Other - Org Name:INNOVATIVE EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LARCOM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:816-444-2393
Mailing Address - Street 1:8025 STATE LINE RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-2016
Mailing Address - Country:US
Mailing Address - Phone:816-444-2393
Mailing Address - Fax:816-444-2394
Practice Address - Street 1:8025 STATE LINE RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-2016
Practice Address - Country:US
Practice Address - Phone:816-444-2393
Practice Address - Fax:816-444-2394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-05
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO3126152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU45316Medicare UPIN