Provider Demographics
NPI:1295729846
Name:MARK BETTENCOURT, O.D. PC
Entity type:Organization
Organization Name:MARK BETTENCOURT, O.D. PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-456-8900
Mailing Address - Street 1:1405 W US HIGHWAY 24
Mailing Address - Street 2:
Mailing Address - City:WAMEGO
Mailing Address - State:KS
Mailing Address - Zip Code:66547-1256
Mailing Address - Country:US
Mailing Address - Phone:785-456-8900
Mailing Address - Fax:785-456-8902
Practice Address - Street 1:1405 W US HIGHWAY 24
Practice Address - Street 2:
Practice Address - City:WAMEGO
Practice Address - State:KS
Practice Address - Zip Code:66547-1256
Practice Address - Country:US
Practice Address - Phone:785-456-8900
Practice Address - Fax:785-456-8902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1234-2152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS410014173OtherRAILROAD MEDICARE
KS0692920001OtherDMERC
KS650563OtherBCBS
KS650563Medicare ID - Type UnspecifiedGROUP ID
KS0692920001Medicare NSC