Provider Demographics
NPI:1811125164
Name:CRENSHAW, KEVIN J (DISPENSING OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:J
Last Name:CRENSHAW
Suffix:
Gender:M
Credentials:DISPENSING OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 ATHOL STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107
Mailing Address - Country:US
Mailing Address - Phone:413-627-9290
Mailing Address - Fax:
Practice Address - Street 1:45 ATHOL ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107
Practice Address - Country:US
Practice Address - Phone:413-627-9290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5655156FC0800X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact Lens