Provider Demographics
NPI:1700995750
Name:HIESTERMAN FAMILY EYE CARE, LLC
Entity Type:Organization
Organization Name:HIESTERMAN FAMILY EYE CARE, LLC
Other - Org Name:RYAN L. HIESTERMAN, O.D., LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HIESTERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:785-632-6100
Mailing Address - Street 1:532 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CLAY CENTER
Mailing Address - State:KS
Mailing Address - Zip Code:67432-2902
Mailing Address - Country:US
Mailing Address - Phone:785-632-6100
Mailing Address - Fax:785-632-6101
Practice Address - Street 1:532 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CLAY CENTER
Practice Address - State:KS
Practice Address - Zip Code:67432-2902
Practice Address - Country:US
Practice Address - Phone:785-632-6100
Practice Address - Fax:785-632-6101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1656152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200259350BMedicaid
KSP00173182OtherRAILROAD MEDICARE
KS481170OtherFIRST GUARD
KS481170OtherFIRST GUARD
KS200259350BMedicaid
KS5278900001Medicare NSC