Healthcare Provider Details

I. General information

NPI: 1326344599
Provider Name (Legal Business Name): KANSAS CITY VISION PERFORMANCE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2011
Last Update Date: 02/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10875 GRANDVIEW ST SUITE 2260
OVERLAND PARK KS
66210-1561
US

IV. Provider business mailing address

10875 GRANDVIEW ST SUITE 2260
OVERLAND PARK KS
66210-1561
US

V. Phone/Fax

Practice location:
  • Phone: 913-469-8686
  • Fax: 913-469-8688
Mailing address:
  • Phone: 913-469-8686
  • Fax: 913-469-8688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number1105-3
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number17-00652
License Number StateKS

VIII. Authorized Official

Name: DR. JOHN CHARLES METZGER
Title or Position: OPTOMETRIST
Credential: OD
Phone: 913-469-8686