Provider Demographics
NPI:1649448507
Name:KENNETH H. BALLENTINE OD INC.
Entity type:Organization
Organization Name:KENNETH H. BALLENTINE OD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:H
Authorized Official - Last Name:BALLENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:408-255-0576
Mailing Address - Street 1:5275 PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129-5031
Mailing Address - Country:US
Mailing Address - Phone:408-255-0576
Mailing Address - Fax:
Practice Address - Street 1:5275 PROSPECT RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129-5031
Practice Address - Country:US
Practice Address - Phone:408-255-0576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6863T152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0068630Medicaid
T10429Medicare UPIN
CASD0068630Medicaid
FS797AMedicare PIN