MEDICARE: KANSAS CITY OPTICAL, LLC

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

General Provider Information

NPI Number	:	1467153601
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KANSAS CITY OPTICAL, LLC

Provider Business Mailing Address
First Line	:	13803 W 82ND TER
Second Line	:
City	:	LENEXA
State	:	KS
Zip	:	66215-4168
Country	:	US
Telephone Number	:	913-717-9296
Fax Number	:	816-817-3769

Provider Business Practice Location Address
First Line	:	4609 INDEPENDENCE AVE
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64124-2927
Country	:	US
Telephone Number	:	913-717-9296
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MATTHEW BROBERG
Credential	:	OD
Telephone Number	:	913-717-9296

Provider Enumeration Date	:	03/14/2023
Last Update Date	:	03/14/2023

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