Provider Demographics
NPI:1881688380
Name:KLINE, LYNETTE (OD)
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:
Last Name:KLINE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 CYPRESS ST
Mailing Address - Street 2:STE A
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-5411
Mailing Address - Country:US
Mailing Address - Phone:707-961-1037
Mailing Address - Fax:
Practice Address - Street 1:510 CYPRESS ST
Practice Address - Street 2:STE A
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5411
Practice Address - Country:US
Practice Address - Phone:707-961-1037
Practice Address - Fax:707-961-0346
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9506152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0095060Medicaid
CA4939170001Medicare NSC
CASD0095060Medicaid
CASD0095060Medicare PIN