Provider Demographics
NPI:1669790911
Name:KANE, KENNETH JOHN (CO)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOHN
Last Name:KANE
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:762 W MICHIGAN AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1978
Mailing Address - Country:US
Mailing Address - Phone:517-780-9073
Mailing Address - Fax:517-780-9673
Practice Address - Street 1:762 W MICHIGAN AVE
Practice Address - Street 2:SUITE D
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1978
Practice Address - Country:US
Practice Address - Phone:517-780-9073
Practice Address - Fax:517-780-9673
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
6411350001Medicare NSC