Provider Demographics
NPI:1578833836
Name:KENNYS OPTICAL INC
Entity Type:Organization
Organization Name:KENNYS OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED OPTICIAN/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:KANE
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:517-780-9073
Mailing Address - Street 1:762 W MICHIGAN AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1978
Mailing Address - Country:US
Mailing Address - Phone:517-780-9073
Mailing Address - Fax:517-780-9673
Practice Address - Street 1:762 W MICHIGAN AVE
Practice Address - Street 2:SUITE D
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1978
Practice Address - Country:US
Practice Address - Phone:517-780-9073
Practice Address - Fax:517-780-9673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5100005993800044100332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1669790911Medicare NSC
MI6411350001Medicare PIN