Provider Demographics
NPI:1821452236
Name:GROLEAU, KENNETH LAURENCE
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LAURENCE
Last Name:GROLEAU
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 1:225 BLANDING BLVD.
Mailing Address - Street 2:KENS UNITED OPTICAL
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073
Mailing Address - Country:US
Mailing Address - Phone:904-276-4611
Mailing Address - Fax:904-276-4328
Practice Address - Street 1:225 BLANDING BLVD.
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073
Practice Address - Country:US
Practice Address - Phone:904-276-4611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLD03062156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician