Provider Demographics
NPI:1740393107
Name:CLINE, KEVIN B (OD,FCOVD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:B
Last Name:CLINE
Suffix:
Gender:M
Credentials:OD,FCOVD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 SE LOUIS DR
Mailing Address - Street 2:
Mailing Address - City:MULVANE
Mailing Address - State:KS
Mailing Address - Zip Code:67110-1205
Mailing Address - Country:US
Mailing Address - Phone:316-777-0022
Mailing Address - Fax:316-777-4342
Practice Address - Street 1:12111 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67235-8755
Practice Address - Country:US
Practice Address - Phone:316-942-7496
Practice Address - Fax:316-239-2557
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1295152W00000X, 152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100218790CMedicaid
KST91164Medicare UPIN
KS100218790CMedicaid