Provider Demographics
NPI:1104996891
Name:DRS DRIVER & CLARK PA
Entity type:Organization
Organization Name:DRS DRIVER & CLARK PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENTON
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:DRIVER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:785-392-2126
Mailing Address - Street 1:407 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:KS
Mailing Address - Zip Code:67467-2315
Mailing Address - Country:US
Mailing Address - Phone:785-392-2126
Mailing Address - Fax:785-392-2180
Practice Address - Street 1:407 W 2ND ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:KS
Practice Address - Zip Code:67467-2315
Practice Address - Country:US
Practice Address - Phone:785-392-2126
Practice Address - Fax:785-392-2180
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DRS DRIVER & CLARK PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-09
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS1325152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS4196900001Medicare NSC
650504Medicare PIN