Healthcare Provider Details

I. General information

NPI: 1508919960
Provider Name (Legal Business Name): KEVIN C SORENSEN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2186 HARRIS AVE NE STE 1
PALM BAY FL
32905-4044
US

IV. Provider business mailing address

2186 HARRIS AVE NE STE 1
PALM BAY FL
32905-4044
US

V. Phone/Fax

Practice location:
  • Phone: 321-724-2020
  • Fax:
Mailing address:
  • Phone: 321-724-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4879
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: