Provider Demographics
NPI:1548210453
Name:LANE, KEVIN (OD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:LANE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2390 E FLORIDA AVE
Mailing Address - Street 2:#207
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-4707
Mailing Address - Country:US
Mailing Address - Phone:951-652-6100
Mailing Address - Fax:951-658-7548
Practice Address - Street 1:2390 E FLORIDA AVE
Practice Address - Street 2:#207
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544-4707
Practice Address - Country:US
Practice Address - Phone:951-652-6100
Practice Address - Fax:951-658-7548
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10632152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU60214Medicare UPIN