Basic Information
| Provider Information | |||||||||
| NPI: | 1134209901 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUCHER | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1644 NW GARRETT | ||||||||
| Address2: | |||||||||
| City: | BLUE SPRINGS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166412964 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4027 MILL ST | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641113008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165611665 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 01/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1735 | KS | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 2005027604 | MO | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 152W00000X | 01 | MO | OPTOMETRY | OTHER |