Basic Information
| Provider Information | |||||||||
| NPI: | 1033162631 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EYE SURGERY CENTER NORTHLAND, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4801CLIFF AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | INDEPENDENCE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164781230 | ||||||||
| FaxNumber: | 8163504585 | ||||||||
| Practice Location | |||||||||
| Address1: | 9401 N OAK TRFY | ||||||||
| Address2: | SUITE 124 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641552233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164781230 | ||||||||
| FaxNumber: | 8163504585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 02/16/2022 | ||||||||
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| AuthorizedOfficialLastName: | HAMILTON | ||||||||
| AuthorizedOfficialFirstName: | MELINDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 8163504536 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EYE CARE, LLC | ||||||||
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| NPICertificationDate: | 02/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 191 | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | P00368401 | 01 | MO | RAILROAD MEDICARE | OTHER |