Provider Demographics
NPI:1013142694
Name:STATE LINE EYE CARE CENTER, PC
Entity Type:Organization
Organization Name:STATE LINE EYE CARE CENTER, PC
Other - Org Name:BROOKSIDE EYE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LILLIAM (LILY)
Authorized Official - Middle Name:S
Authorized Official - Last Name:YOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-333-8600
Mailing Address - Street 1:520 E 63RD ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64110-3330
Mailing Address - Country:US
Mailing Address - Phone:816-333-8600
Mailing Address - Fax:816-444-3304
Practice Address - Street 1:520 E 63RD ST
Practice Address - Street 2:BROOKSIDE EYE CARE CENTER
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64110-3330
Practice Address - Country:US
Practice Address - Phone:816-333-8600
Practice Address - Fax:816-444-3304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-26
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty