Provider Demographics
NPI:1568412344
Name:YEAGER, KENNETH ANTHONY
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ANTHONY
Last Name:YEAGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2304W PARKER RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29617-2123
Mailing Address - Country:US
Mailing Address - Phone:864-246-0964
Mailing Address - Fax:
Practice Address - Street 1:2304 W PARKER RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29617-2123
Practice Address - Country:US
Practice Address - Phone:864-246-0964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1027152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD10272Medicaid
SCD10272Medicaid
SC0983580001Medicare NSC
SCU51114Medicare UPIN