Provider Demographics
NPI:1134372873
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:DR
Authorized Official - First Name:ABBIE
Authorized Official - Middle Name:NELL
Authorized Official - Last Name:RONDEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
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 1:1504 N CHURCH RD STE C
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-7163
Practice Address - Country:US
Practice Address - Phone:816-781-3442
Practice Address - Fax:816-415-9743
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BENNETT EYECARE MIDWEST, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-28
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO535840201Medicaid
MO505840207Medicaid
1528041860OtherNPI
1811159361OtherNPI
MO1669455747OtherNPI
MO318693827Medicaid
1407839756OtherNPI
MO312478241Medicaid
MO316013606Medicaid
MO1669455747OtherNPI
MOU92817Medicare UPIN
1528041860OtherNPI
MOU05608Medicare UPIN
MOL80C118Medicare UPIN
MO505840207Medicaid
MOU55449Medicare UPIN
MO535840201Medicaid