Healthcare Provider Details

I. General information

NPI: 1386619062
Provider Name (Legal Business Name): KEVIN KOLENDA OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 07/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 N 16TH ST
PHOENIX AZ
85016-5319
US

IV. Provider business mailing address

PO BOX 31001-0698
PASADENA CA
91110-0698
US

V. Phone/Fax

Practice location:
  • Phone: 602-263-1200
  • Fax: 602-200-5383
Mailing address:
  • Phone: 602-263-1200
  • Fax: 602-200-5383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number576
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTO3255
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: