MEDICARE: NORTHLAND OPTICAL CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1528351889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHLAND OPTICAL CENTER, LLC

Provider Business Mailing Address
First Line	:	1200 LANDMARK AVE
Second Line	:
City	:	LIBERTY
State	:	MO
Zip	:	64068-1051
Country	:	US
Telephone Number	:	816-792-1900
Fax Number	:	816-792-3548

Provider Business Practice Location Address
First Line	:	8660 N GREEN HILLS RD
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64154-1912
Country	:	US
Telephone Number	:	816-584-1901
Fax Number	:	816-584-1902

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	GRACE A BETTERTON
Credential	:
Telephone Number	:	816-792-1900

Provider Enumeration Date	:	05/19/2011
Last Update Date	:	05/19/2011

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