Provider Demographics
NPI:1225113863
Name:K & K OPTICAL INC
Entity Type:Organization
Organization Name:K & K OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:KLOSOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-777-2830
Mailing Address - Street 1:28209 7 MILE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-3750
Mailing Address - Country:US
Mailing Address - Phone:248-777-2830
Mailing Address - Fax:248-777-9376
Practice Address - Street 1:28209 7 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3750
Practice Address - Country:US
Practice Address - Phone:248-777-2830
Practice Address - Fax:248-777-9376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMM002314152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMM002314OtherOPTEMETRIC LISCENSE
MIOM77260Medicare ID - Type UnspecifiedHCFA #
MI0432970001Medicare ID - Type UnspecifiedDNMERC-B
MIT33804Medicare UPIN