Provider Demographics
NPI:1770615601
Name:STATE LINE EYE CARE CENTER, PC
Entity type:Organization
Organization Name:STATE LINE EYE CARE CENTER, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:
Authorized Official - Last Name:SABATES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
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:816-444-3341
Practice Address - Street 1:424 E NORTH AVE
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:MO
Practice Address - Zip Code:64012-2017
Practice Address - Country:US
Practice Address - Phone:816-322-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE LINE EYE CARE CENTER, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-09
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO328147707Medicaid
MO19517041OtherBCBS
MO328147707Medicaid