Provider Demographics
NPI:1255207528
Name:LEVERETTE, KENDALE
Entity type:Individual
Prefix:
First Name:KENDALE
Middle Name:
Last Name:LEVERETTE
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 1:19185 ASBURY PARK
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-2402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19185 ASBURY PARK
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2402
Practice Address - Country:US
Practice Address - Phone:313-800-8722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-14
Last Update Date:2025-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBRIGHT156FC0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Single Specialty