Provider Demographics
NPI:1447391024
Name:H. KENNETH KOPOLOW, OD & ASSOC. PROF. CORP.
Entity Type:Organization
Organization Name:H. KENNETH KOPOLOW, OD & ASSOC. PROF. CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HARLAN
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:KOPOLOW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:702-733-6764
Mailing Address - Street 1:7361 W LAKE MEAD BLVD
Mailing Address - Street 2:STE. 104
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-1040
Mailing Address - Country:US
Mailing Address - Phone:702-733-6764
Mailing Address - Fax:702-255-5795
Practice Address - Street 1:1300 W SUNSET RD
Practice Address - Street 2:SUITE #1617
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-6620
Practice Address - Country:US
Practice Address - Phone:702-341-7254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KOPOLOW & GIRISGEN OD, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-08
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100507865Medicaid
NVV102758Medicare PIN