Icke, Russell Wayne
Icke, Russell Wayne is an sole proprietor health care provider with primary practice located at 7050 E Lincoln St , Wichita KS 67207-2638. He recently has only one registered license in Eye and Vision Services Providers / Optometrist, which is considered as his primary health care specialty. Icke, Russell Wayne can be contacted via phone (316) 683-9671.Contact Information
Primary practice address
7050 E Lincoln St
Wichita KS 67207-2638
Phone: (316) 683-9671
Fax: (316) 683-0168
Website:
Health care specialties
| Specialty | Code | License # | State |
|---|---|---|---|
| Eye and Vision Services Providers / Optometrist | 152W00000X | 10352 | Kansas |
Profile Details
| NPI number | 1134113319 |
|---|---|
| LBN Legal business name | Icke, Russell Wayne |
| Credentials | Doctor of Optometry (OD) |
| Entity | Individual |
| Sole proprietor 1 | Yes |
| Enumeration date | Sep 2nd, 2005 |
| Last updated | Jul 28th, 2010 - about 16 years ago |
1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.
Identifiers
| State | Type | Number | Issuer |
|---|---|---|---|
| All States | NPI | 1134113319 | NPPES |
| Kansas | MEDICAID | 10090970A | |
| Kansas | Other | 826580253 | |
| Kansas | Other | 0212690001 |
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