Provider Demographics
NPI:1235624289
Name:KREGG KOONS O.D., INC.
Entity Type:Organization
Organization Name:KREGG KOONS O.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KREGG
Authorized Official - Middle Name:C
Authorized Official - Last Name:KOONS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:765-289-4727
Mailing Address - Street 1:3300 W FOX RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5201
Mailing Address - Country:US
Mailing Address - Phone:765-289-4727
Mailing Address - Fax:
Practice Address - Street 1:3300 PURDUE AVE.
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304
Practice Address - Country:US
Practice Address - Phone:765-288-1935
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KREGG KOONS O.D., INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-22
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002701152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100376600Medicaid