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General NPI Number Information
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NPI Number | 1467153601
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Entity Type | Organization
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Legal Business Name | KANSAS CITY OPTICAL, LLC
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Dates
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Enumeration Date | 03/14/2023
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Last Update Date | 03/14/2023
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Provider Practice Location Address
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Address Line | 4609 INDEPENDENCE AVE
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City | KANSAS CITY
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State | MO
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Zip | 64124-2927
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Country | US
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Telephone | 913-717-9296
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Fax |
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Provider Business Mailing Address
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Address Line | 13803 W 82ND TER
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City | LENEXA
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State | KS
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Zip | 66215-4168
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Country | US
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Telephone | 913-717-9296
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Fax | 816-817-3769
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Authorized Official
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Title or Position | OWNER
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Name | MATTHEW BROBERG
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Credential | OD
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Telephone | 913-717-9296
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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 |
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License Number State |
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