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General NPI Number Information
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NPI Number | 1295729846
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Entity Type | Organization
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Legal Business Name | MARK BETTENCOURT, O.D. PC
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Dates
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Enumeration Date | 09/08/2005
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Last Update Date | 12/14/2011
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Provider Practice Location Address
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Address Line | 1405 W US HIGHWAY 24
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City | WAMEGO
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State | KS
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Zip | 66547-1256
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Country | US
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Telephone | 785-456-8900
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Fax | 785-456-8902
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Provider Business Mailing Address
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Address Line | 1405 W US HIGHWAY 24
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City | WAMEGO
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State | KS
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Zip | 66547-1256
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Country | US
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Telephone | 785-456-8900
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Fax | 785-456-8902
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | LINDA J WARREN
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Credential |
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Telephone | 785-456-8900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1234-2
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License Number State | KS
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