Provider Demographics
NPI:1215978622
Name:STATE LINE EYE CARE CENTER, PC
Entity type:Organization
Organization Name:STATE LINE EYE CARE CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/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:816-444-2900
Mailing Address - Street 1:7701 STATE LINE RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-1635
Mailing Address - Country:US
Mailing Address - Phone:816-444-2900
Mailing Address - Fax:816-444-3304
Practice Address - Street 1:7701 STATE LINE RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-1635
Practice Address - Country:US
Practice Address - Phone:816-444-2900
Practice Address - Fax:816-444-3304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO19517011OtherBLUE CROSS BLUE SHIELD
MO509417606Medicaid
MO509417606Medicaid