Healthcare Provider Details

I. General information

NPI: 1891707584
Provider Name (Legal Business Name): KIMBERLY S MOLTER OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 01/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 BRIDGE ST
CHARLEVOIX MI
49720-1602
US

IV. Provider business mailing address

PO BOX 2027
KALKASKA MI
49646-2027
US

V. Phone/Fax

Practice location:
  • Phone: 231-547-7800
  • Fax: 231-547-7874
Mailing address:
  • Phone: 231-258-9781
  • Fax: 231-258-0616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003200
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: