Healthcare Provider Details

I. General information

NPI: 1639290505
Provider Name (Legal Business Name): GODSHALL QUALITY EYECARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 01/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2248 SW STATE ROUTE 7
BLUE SPRINGS MO
64014
US

IV. Provider business mailing address

2248 SW STATE ROUTE 7
BLUE SPRINGS MO
64014
US

V. Phone/Fax

Practice location:
  • Phone: 816-228-1414
  • Fax: 816-228-2376
Mailing address:
  • Phone: 816-228-1414
  • Fax: 816-228-2376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT03377
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number557
License Number StateMO

VIII. Authorized Official

Name: DR. WADE GODSHALL
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 816-228-1414