MEDICARE: BROOKSIDE OPTICAL

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	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1841439098
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOKSIDE OPTICAL

Provider Business Mailing Address
First Line	:	14130 W 119TH ST
Second Line	:
City	:	OLATHE
State	:	KS
Zip	:	66062-6621
Country	:	US
Telephone Number	:	913-390-9300
Fax Number	:	913-390-9301

Provider Business Practice Location Address
First Line	:	14130 W 119TH ST
Second Line	:
City	:	OLATHE
State	:	KS
Zip	:	66062-6621
Country	:	US
Telephone Number	:	913-390-9300
Fax Number	:	913-390-9301

Authorized Official
Title or Position	:	OPTICIAN
Name	:	MR. R LEON BUTLER
Credential	:
Telephone Number	:	913-390-9300

Provider Enumeration Date	:	02/11/2009
Last Update Date	:	02/11/2009

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Directions to “BROOKSIDE OPTICAL ” Practice Location

Language	Start Address	Practice Location

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