MEDICARE: BRENNAN MICHELLE RIDINGS O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2016015962	MO
2	152W00000X	Optometrist	2021	KS

General Provider Information

NPI Number	:	1285081828
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENNAN MICHELLE RIDINGS O.D.

Provider Business Mailing Address
First Line	:	8509 STATE LINE RD
Second Line	:	TARGET OPTICAL
City	:	KANSAS CITY
State	:	MO
Zip	:	64114-2723
Country	:	US
Telephone Number	:	816-410-2982
Fax Number	:	816-333-3667

Provider Business Practice Location Address
First Line	:	8509 STATE LINE RD
Second Line	:	TARGET OPTICAL
City	:	KANSAS CITY
State	:	MO
Zip	:	64114-2723
Country	:	US
Telephone Number	:	816-410-2982
Fax Number	:	816-333-3667

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2016
Last Update Date	:	01/18/2017

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