Provider Demographics
NPI:1255778270
Name:KLEINEBREIL OPTOMETRY PLLC
Entity type:Organization
Organization Name:KLEINEBREIL OPTOMETRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:LEAH
Authorized Official - Last Name:TANKE-KLEINEBREIL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:231-215-0103
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49734-0421
Mailing Address - Country:US
Mailing Address - Phone:989-732-7518
Mailing Address - Fax:989-732-4205
Practice Address - Street 1:927 S OTSEGO AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1783
Practice Address - Country:US
Practice Address - Phone:989-732-7518
Practice Address - Fax:989-732-4205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-30
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004610152WC0802X, 152WL0500X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N95760Medicare PIN
MI6792710001Medicare NSC