=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770613721
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAREN OPTOMETRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2007
-----------------------------------------------------
Last Update Date | 09/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2121 N TYLER RD SUITE 302
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67212-4920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-729-8600
-----------------------------------------------------
Fax | 316-773-3160
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2121 N TYLER RD SUITE 302
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67212-4900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-729-8600
-----------------------------------------------------
Fax | 316-773-3160
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | J WESLEY WAREN
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 316-729-8600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1389-3
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------