Provider Demographics
NPI:1912290263
Name:NORTHLAND OPTICAL CENTER, LLC
Entity Type:Organization
Organization Name:NORTHLAND OPTICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BETTERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-792-1900
Mailing Address - Street 1:1200 LANDMARK AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-1051
Mailing Address - Country:US
Mailing Address - Phone:816-792-1900
Mailing Address - Fax:816-792-3548
Practice Address - Street 1:1200 LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-1051
Practice Address - Country:US
Practice Address - Phone:816-792-1900
Practice Address - Fax:816-792-3548
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHLAND EYE SPECIALISTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier