=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033162631
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE SURGERY CENTER-NORTHLAND LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2006
-----------------------------------------------------
Last Update Date | 07/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9401 N OAK TRFY SUITE 124
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64155-2233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-478-1230
-----------------------------------------------------
Fax | 816-350-4585
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4801CLIFF AVE SUITE 100
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-478-1230
-----------------------------------------------------
Fax | 816-350-4585
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE ASSISTANT
-----------------------------------------------------
Name | MELINDA HAMILTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 816-350-4536
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 191
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------