Provider Demographics
NPI:1891938163
Name:JENNY M. KISNER OD LLC
Entity Type:Organization
Organization Name:JENNY M. KISNER OD LLC
Other - Org Name:BROOKSTONE EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:M
Authorized Official - Last Name:KISNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:940-761-2317
Mailing Address - Street 1:1508 BROOK AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-5604
Mailing Address - Country:US
Mailing Address - Phone:940-761-2317
Mailing Address - Fax:940-761-2992
Practice Address - Street 1:1508 BROOK AVE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-5604
Practice Address - Country:US
Practice Address - Phone:940-761-2317
Practice Address - Fax:940-761-2992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-15
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX208393302Medicaid
TX208393302Medicaid