Provider Demographics
NPI:1396939260
Name:M.T. ALDRICH, OD, OPTOMETRY, PC
Entity type:Organization
Organization Name:M.T. ALDRICH, OD, OPTOMETRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:T
Authorized Official - Last Name:ALDRICH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:816-279-2339
Mailing Address - Street 1:1427 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2459
Mailing Address - Country:US
Mailing Address - Phone:816-279-2339
Mailing Address - Fax:816-279-0110
Practice Address - Street 1:1427 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2459
Practice Address - Country:US
Practice Address - Phone:816-279-2339
Practice Address - Fax:816-279-0110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02103332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO310043104Medicaid
MOT42477Medicare UPIN
MO0648520001Medicare NSC
MO310043104Medicaid