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General NPI Number Information
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NPI Number | 1972683746
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Entity Type | Individual
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Provider Name | DEAMBRA LEA BOUCHER O.D.
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Gender | Female
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Dates
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Enumeration Date | 10/16/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 13900 E US HIGHWAY 40 STE A
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City | INDEPENDENCE
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State | MO
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Zip | 64055-5877
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Country | US
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Telephone | 816-478-0500
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Fax |
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Provider Business Mailing Address
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Address Line | 1644 NW GARRETT
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City | BLUE SPRINGS
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State | MO
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Zip | 64015
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Country | US
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Telephone | 316-641-4219
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 2006016870
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1712
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License Number State | KS
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