Provider Demographics
NPI:1629240858
Name:KENNETH R GIFT OD
Entity Type:Organization
Organization Name:KENNETH R GIFT OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNTH
Authorized Official - Middle Name:R
Authorized Official - Last Name:GIFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-374-0154
Mailing Address - Street 1:886 ROUTE 522
Mailing Address - Street 2:
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-9712
Mailing Address - Country:US
Mailing Address - Phone:570-374-0154
Mailing Address - Fax:570-374-0155
Practice Address - Street 1:886 ROUTE 522
Practice Address - Street 2:
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-9712
Practice Address - Country:US
Practice Address - Phone:570-374-0154
Practice Address - Fax:570-374-0155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAG000099332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAT28139Medicare UPIN
PA0278060001Medicare NSC