Healthcare Provider Details

I. General information

NPI: 1316357569
Provider Name (Legal Business Name): KIMBERLY PENIX LAAN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 02/01/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 PROVIDENCE PARK DR E
MOBILE AL
36695-4617
US

IV. Provider business mailing address

601 PROVIDENCE PARK DR E
MOBILE AL
36695-4617
US

V. Phone/Fax

Practice location:
  • Phone: 251-650-2020
  • Fax: 251-650-1010
Mailing address:
  • Phone: 251-650-2020
  • Fax: 251-650-1010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number00000
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3450
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT-214-TA-975
License Number StateAL
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS-D45-TA-975
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: