Provider Demographics
NPI:1497133011
Name:KEN P OPTOMETRY CORP
Entity Type:Organization
Organization Name:KEN P OPTOMETRY CORP
Other - Org Name:DR. KEN PETERSON FAMILY OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:805-473-9393
Mailing Address - Street 1:911 OAK PARK BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3405
Mailing Address - Country:US
Mailing Address - Phone:805-473-9393
Mailing Address - Fax:805-473-1974
Practice Address - Street 1:911 OAK PARK BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3405
Practice Address - Country:US
Practice Address - Phone:805-473-9393
Practice Address - Fax:805-473-1974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty