Basic Information
| Provider Information | |||||||||
| NPI: | 1396116935 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KANNARR EYE CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 W 29TH ST | ||||||||
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| City: | PITTSBURG | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667622696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202351737 | ||||||||
| FaxNumber: | 6202350358 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 N SUMMIT ST | ||||||||
| Address2: | |||||||||
| City: | GIRARD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667431360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207244800 | ||||||||
| FaxNumber: | 6207244034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2015 | ||||||||
| LastUpdateDate: | 10/08/2015 | ||||||||
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| AuthorizedOfficialLastName: | KANNARR | ||||||||
| AuthorizedOfficialFirstName: | SHANE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/OD | ||||||||
| AuthorizedOfficialTelephone: | 6207244800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1699 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 200366110D | 05 | KS | MEDICAID |