Basic Information
| Provider Information | |||||||||
| NPI: | 1538695978 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FARRELL | ||||||||
| FirstName: | GRACE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4801 S CLIFF AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | INDEPENDENCE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640556954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164781230 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4801 E LINWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641282226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8168614700 | ||||||||
| FaxNumber: | 8169223382 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2017 | ||||||||
| LastUpdateDate: | 02/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2018002791 | MO | Y | Eye and Vision Services Providers | Optometrist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.