=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093121097
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE EYE GALLERY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2014
-----------------------------------------------------
Last Update Date | 07/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3084 N. MAIZE RD
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-315-0321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2146 N COLLECTIVE LN STE 110
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67206-3574
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OD/CEO
-----------------------------------------------------
Name | DR. MEGAN BALDWIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 316-315-0321
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1889
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------