Provider Demographics
NPI:1518918077
Name:KACZMARCZYK, KYLIE LOUISE (OD)
Entity Type:Individual
Prefix:DR
First Name:KYLIE
Middle Name:LOUISE
Last Name:KACZMARCZYK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8288 S MACKINAC TRL
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-9293
Mailing Address - Country:US
Mailing Address - Phone:906-635-6885
Mailing Address - Fax:
Practice Address - Street 1:128 W SPRUCE ST
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1959
Practice Address - Country:US
Practice Address - Phone:906-635-9600
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004198152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U97791Medicare UPIN