Provider Demographics
NPI:1336184993
Name:EYE SURGERY CENTER OF WICHITA, LLC
Entity Type:Organization
Organization Name:EYE SURGERY CENTER OF WICHITA, LLC
Other - Org Name:TEAM VISION SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFRREY
Authorized Official - Middle Name:E
Authorized Official - Last Name:SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:1A BURTON HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6187
Mailing Address - Country:US
Mailing Address - Phone:615-665-1283
Mailing Address - Fax:615-234-1720
Practice Address - Street 1:6100 E CENTRAL AVE STE 5
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-4237
Practice Address - Country:US
Practice Address - Phone:316-681-2020
Practice Address - Fax:316-684-4939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSSO87004261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1181OtherPPK & PHS
KS490004218OtherRAILROAD MEDICARE
KS100343550AMedicaid
KS490004218OtherRAILROAD MEDICARE
KS=========-67208-0000OtherTRICARE