Basic Information
Provider Information | |||||||||
NPI: | 1114984390 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BEEK | ||||||||
FirstName: | LOREN | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | O.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4801 S CLIFF AVE | ||||||||
Address2: | SUITE 100 | ||||||||
City: | INDEPENDENCE | ||||||||
State: | MO | ||||||||
PostalCode: | 640557015 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8164781230 | ||||||||
FaxNumber: | 8163504585 | ||||||||
Practice Location | |||||||||
Address1: | 4741 S COCHISE DR | ||||||||
Address2: |   | ||||||||
City: | INDEPENDENCE | ||||||||
State: | MO | ||||||||
PostalCode: | 640556974 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8164781230 | ||||||||
FaxNumber: | 8163504585 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/29/2006 | ||||||||
LastUpdateDate: | 05/12/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT-2522 | CO | Y |   | Eye and Vision Services Providers | Optometrist |   | 152W00000X | 573 | NM | N |   | Eye and Vision Services Providers | Optometrist |   | 152W00000X | 2016008476 | MO | N |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 16821092 | 05 | CO |   | MEDICAID | 840851676009 | 01 |   | ROCKY MOUNTAIN HEALTH PLANS | OTHER |