Healthcare Provider Details

I. General information

NPI: 1538695978
Provider Name (Legal Business Name): GRACE FARRELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2017
Last Update Date: 02/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 E LINWOOD BLVD
KANSAS CITY MO
64128-2226
US

IV. Provider business mailing address

4801 S CLIFF AVE STE 100
INDEPENDENCE MO
64055-6954
US

V. Phone/Fax

Practice location:
  • Phone: 816-861-4700
  • Fax: 816-922-3382
Mailing address:
  • Phone: 816-478-1230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2018002791
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: