Healthcare Provider Details

I. General information

NPI: 1295730992
Provider Name (Legal Business Name): KENNETH RICHARD HANSEN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 02/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 N ANKENY BLVD
ANKENY IA
50023-1711
US

IV. Provider business mailing address

311 N ANKENY BLVD
ANKENY IA
50023-1711
US

V. Phone/Fax

Practice location:
  • Phone: 515-964-1671
  • Fax: 515-964-1714
Mailing address:
  • Phone: 515-964-1671
  • Fax: 515-964-1714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number01592
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: