Provider Demographics
NPI:1205018413
Name:KIP NEWELL OD LLC
Entity Type:Organization
Organization Name:KIP NEWELL OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-209-0540
Mailing Address - Street 1:131 W WYANDOT AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:43351-1348
Mailing Address - Country:US
Mailing Address - Phone:419-209-0540
Mailing Address - Fax:419-209-0540
Practice Address - Street 1:131 W WYANDOT AVE
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-1348
Practice Address - Country:US
Practice Address - Phone:419-209-0540
Practice Address - Fax:419-209-0540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2011-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4617 T1363152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3135986Medicaid
OHSP05291Medicare PIN
OHDB7120Medicare PIN
OHDQ8875Medicare PIN
OH6497470001Medicare NSC
OH9391571Medicare PIN
OH3135986Medicaid