Provider Demographics
NPI:1801825591
Name:KENSINGTON OPTOMETRY INC
Entity Type:Organization
Organization Name:KENSINGTON OPTOMETRY INC
Other - Org Name:RUSSELL COTTERAL DBA KENSINGTON OPTOMETRY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT, OWNER, OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:COTTERAL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:510-527-1714
Mailing Address - Street 1:396 COLUSA AVE
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:94707-1209
Mailing Address - Country:US
Mailing Address - Phone:510-527-1714
Mailing Address - Fax:510-527-1715
Practice Address - Street 1:396 COLUSA AVE
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:CA
Practice Address - Zip Code:94707-1209
Practice Address - Country:US
Practice Address - Phone:510-527-1714
Practice Address - Fax:510-527-1715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5955152W00000X
CA9134152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1619911047OtherNPI (INDIVIDUAL)
ZZZ04659ZMedicare PIN
CAFY844AMedicare PIN