Provider Demographics
NPI:1417148669
Name:KALAMAZOO OPTOMETRY PC
Entity Type:Organization
Organization Name:KALAMAZOO OPTOMETRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIBOLET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-382-6500
Mailing Address - Street 1:6101 NEWPORT RD
Mailing Address - Street 2:STE A
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-9233
Mailing Address - Country:US
Mailing Address - Phone:269-382-6500
Mailing Address - Fax:269-382-2286
Practice Address - Street 1:6101 NEWPORT RD
Practice Address - Street 2:STE A
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-9233
Practice Address - Country:US
Practice Address - Phone:269-382-6500
Practice Address - Fax:269-382-2286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002440152W00000X
MI4901004197152W00000X
MI4901002237152W00000X
MI4901002352152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI945006016Medicaid
MI945031190Medicaid
MI900C947460OtherBLUE CROSS BLUE SHIELD
MI945006007Medicaid
MI944536386Medicaid
MI945006016Medicaid
MI0C94746Medicare PIN
MI900C947460OtherBLUE CROSS BLUE SHIELD
MI945031190Medicaid
MI944536386Medicaid
MIC94746003Medicare PIN