Healthcare Provider Details

I. General information

NPI: 1407038508
Provider Name (Legal Business Name): KATHLEEN D KELTZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 12/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 9TH ST
HAWARDEN IA
51023-2220
US

IV. Provider business mailing address

605 9TH ST
HAWARDEN IA
51023-2220
US

V. Phone/Fax

Practice location:
  • Phone: 712-551-1603
  • Fax: 712-551-1490
Mailing address:
  • Phone: 712-551-1603
  • Fax: 712-551-1490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number01646
License Number StateIA

VIII. Authorized Official

Name: DR. KATHLEEN D KELTZ
Title or Position: OWNER
Credential: O.D.
Phone: 712-551-1603