Provider Demographics
NPI:1518259803
Name:KEN HOLMBERG LLC
Entity Type:Organization
Organization Name:KEN HOLMBERG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMBERG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:517-487-9166
Mailing Address - Street 1:3225 TOWNE CENTRE BLVD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-5620
Mailing Address - Country:US
Mailing Address - Phone:517-487-9166
Mailing Address - Fax:
Practice Address - Street 1:3225 TOWNE CENTRE BLVD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-5620
Practice Address - Country:US
Practice Address - Phone:517-487-9166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-05
Last Update Date:2018-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004504152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty