Basic Information
Provider Information | |||||||||
NPI: | 1629209051 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KANNARR EYE CARE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KANNARR EYE CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 101 W 29TH ST | ||||||||
Address2: | SUITE C | ||||||||
City: | PITTSBURG | ||||||||
State: | KS | ||||||||
PostalCode: | 667622696 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6202351737 | ||||||||
FaxNumber: | 6202300358 | ||||||||
Practice Location | |||||||||
Address1: | 2521 N BROADWAY ST | ||||||||
Address2: |   | ||||||||
City: | PITTSBURG | ||||||||
State: | KS | ||||||||
PostalCode: | 667622620 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6202351737 | ||||||||
FaxNumber: | 6202300358 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/03/2009 | ||||||||
LastUpdateDate: | 08/18/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KANNARR | ||||||||
AuthorizedOfficialFirstName: | SHANE | ||||||||
AuthorizedOfficialMiddleName: | RAY | ||||||||
AuthorizedOfficialTitleorPosition: | OPTOMETRIST/OWNER | ||||||||
AuthorizedOfficialTelephone: | 6202351737 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | OD | ||||||||
NPICertificationDate: | 08/18/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1699 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
No ID Information.