1033203963 NPI number — KENNEDY VISION HEALTH CENTER, LLC

Table of content: (NPI 1033203963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033203963 NPI number — KENNEDY VISION HEALTH CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNEDY VISION HEALTH CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033203963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10600 OLD COUNTY ROAD 15
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55441-6210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-545-8850
Provider Business Mailing Address Fax Number:
763-544-1257

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10600 OLD COUNTY ROAD 15
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55441-6210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-545-8850
Provider Business Practice Location Address Fax Number:
763-544-1257
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TRAVERSE
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
763-545-8850

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 620020600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: DB1166 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 01040808 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2115782 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 417R4KE . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 170285 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 99240 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com