Healthcare Provider Details

I. General information

NPI: 1295729846
Provider Name (Legal Business Name): MARK BETTENCOURT, O.D. PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 W US HIGHWAY 24
WAMEGO KS
66547-1256
US

IV. Provider business mailing address

1405 W US HIGHWAY 24
WAMEGO KS
66547-1256
US

V. Phone/Fax

Practice location:
  • Phone: 785-456-8900
  • Fax: 785-456-8902
Mailing address:
  • Phone: 785-456-8900
  • Fax: 785-456-8902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1234-2
License Number StateKS

VIII. Authorized Official

Name: LINDA J WARREN
Title or Position: OFFICE MANAGER
Credential:
Phone: 785-456-8900