Provider Demographics
NPI:1932411691
Name:KLEINEBREIL, ANNA LEAH (OD)
Entity Type:Individual
Prefix:DR
First Name:ANNA
Middle Name:LEAH
Last Name:KLEINEBREIL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:LEAH
Other - Last Name:TANKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:11082 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-8410
Mailing Address - Country:US
Mailing Address - Phone:231-215-0103
Mailing Address - Fax:
Practice Address - Street 1:927 S OTSEGO AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1783
Practice Address - Country:US
Practice Address - Phone:989-732-7518
Practice Address - Fax:989-732-4205
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-11
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004610152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1932411691Medicaid
MI1932411691Medicaid