Provider Demographics
NPI:1205961919
Name:MCBRATNEY OPTICAL BOUTIQUE
Entity type:Organization
Organization Name:MCBRATNEY OPTICAL BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:FREDRICK
Authorized Official - Last Name:MCBRATNEY
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN CERT 16255
Authorized Official - Phone:913-299-6001
Mailing Address - Street 1:7702 PARALLEL PARKWAY
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66112
Mailing Address - Country:US
Mailing Address - Phone:913-299-6001
Mailing Address - Fax:913-299-6001
Practice Address - Street 1:7702 PARALLEL PARKWAY
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66112
Practice Address - Country:US
Practice Address - Phone:913-299-6001
Practice Address - Fax:913-299-6001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS999800000001183156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS4330380001Medicare ID - Type Unspecified