Provider Demographics
NPI:1639252331
Name:KINGSLEY VISION CENTER PC
Entity Type:Organization
Organization Name:KINGSLEY VISION CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:VANNATTA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:712-378-2640
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:KINGSLEY
Mailing Address - State:IA
Mailing Address - Zip Code:51028-0129
Mailing Address - Country:US
Mailing Address - Phone:712-378-2640
Mailing Address - Fax:712-378-3740
Practice Address - Street 1:125 MAIN STREET
Practice Address - Street 2:
Practice Address - City:KINGSLEY
Practice Address - State:IA
Practice Address - Zip Code:51028
Practice Address - Country:US
Practice Address - Phone:712-378-2640
Practice Address - Fax:712-378-3740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAIA1725152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0177410Medicaid
IA0177410Medicaid
IA1235750001Medicare NSC