Provider Demographics
NPI:1356524011
Name:KENMORE EYECARE CENTER
Entity type:Organization
Organization Name:KENMORE EYECARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:KENMORE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-799-3030
Mailing Address - Street 1:513 N TELEPHONE RD
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-4938
Mailing Address - Country:US
Mailing Address - Phone:405-799-3030
Mailing Address - Fax:405-799-3737
Practice Address - Street 1:513 N TELEPHONE RD
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-4938
Practice Address - Country:US
Practice Address - Phone:405-799-3030
Practice Address - Fax:405-799-3737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2366332B00000X, 332H00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200019180BMedicaid
OK200019180BMedicaid
OKU92397Medicare UPIN
OK5203770001Medicare NSC