Provider Demographics
NPI:1104305564
Name:PROFESSIONAL EYECARE MANAGEMENT INC.
Entity type:Organization
Organization Name:PROFESSIONAL EYECARE MANAGEMENT INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:402-540-0017
Mailing Address - Street 1:11121 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66214-1824
Mailing Address - Country:US
Mailing Address - Phone:785-838-3417
Mailing Address - Fax:913-492-5217
Practice Address - Street 1:3201 S IOWA ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66046-5205
Practice Address - Country:US
Practice Address - Phone:785-383-3417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-07
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1014-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty