Healthcare Provider Details

I. General information

NPI: 1316102726
Provider Name (Legal Business Name): CENTRAL PLAINS EYE MDS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2008
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7717 E 29TH ST N STE 100
WICHITA KS
67226-3444
US

IV. Provider business mailing address

7717 E 29TH ST N SUITE 100
WICHITA KS
67226-3443
US

V. Phone/Fax

Practice location:
  • Phone: 316-712-4970
  • Fax: 316-712-4987
Mailing address:
  • Phone: 316-712-4970
  • Fax: 316-712-4987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. JOHN CHRIS PEDERSEN JR.
Title or Position: OFFICE MANAGER
Credential:
Phone: 316-712-4970