Provider Demographics
NPI:1376272369
Name:KEDZYMAC ENTERPRISES, LLC
Entity Type:Organization
Organization Name:KEDZYMAC ENTERPRISES, LLC
Other - Org Name:CLEVELAND VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:KEDZUF-MCGINNIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-520-4344
Mailing Address - Street 1:9318 SCARLET OAK DR
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-3901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OK
Practice Address - Zip Code:74020-4614
Practice Address - Country:US
Practice Address - Phone:918-385-2245
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-06
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty