MEDICARE: THE RUSSELL EYECARE CENTER

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	152W00000X	Optometrist

General Provider Information

NPI Number	:	1841710563
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE RUSSELL EYECARE CENTER

Provider Business Mailing Address
First Line	:	2601 10TH ST
Second Line	:
City	:	GREAT BEND
State	:	KS
Zip	:	67530-4253
Country	:	US
Telephone Number	:	620-792-2020
Fax Number	:	620-792-2583

Provider Business Practice Location Address
First Line	:	702 N KANSAS ST
Second Line	:
City	:	RUSSELL
State	:	KS
Zip	:	67665-2043
Country	:	US
Telephone Number	:	785-483-2451
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CHAD T PREMER
Credential	:	OD
Telephone Number	:	620-792-2020

Provider Enumeration Date	:	06/23/2017
Last Update Date	:	06/23/2017

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