MEDICARE: AVENTURE VISION OF KANSAS CITY, 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	:	1780158212
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVENTURE VISION OF KANSAS CITY, LLC

Provider Business Mailing Address
First Line	:	2221 E BIJOU ST STE 100
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-8009
Country	:	US
Telephone Number	:	719-576-1850
Fax Number	:

Provider Business Practice Location Address
First Line	:	3716 STATE AVE STE B
Second Line	:
City	:	KANSAS CITY
State	:	KS
Zip	:	66102-3831
Country	:	US
Telephone Number	:	913-298-7360
Fax Number	:

Authorized Official
Title or Position	:	OD/OWNER
Name	:	DR. MICHAEL PHARRIS
Credential	:	OD
Telephone Number	:	719-576-1850

Provider Enumeration Date	:	01/17/2019
Last Update Date	:	09/18/2019

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