Healthcare Provider Details

I. General information

NPI: 1932411691
Provider Name (Legal Business Name): ANNA LEAH KLEINEBREIL O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANNA LEAH TANKE O.D.

II. Dates (important events)

Enumeration Date: 07/11/2010
Last Update Date: 07/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 S OTSEGO AVE
GAYLORD MI
49735-1783
US

IV. Provider business mailing address

11082 LAKE SHORE DR
GAYLORD MI
49735-8410
US

V. Phone/Fax

Practice location:
  • Phone: 989-732-7518
  • Fax: 989-732-4205
Mailing address:
  • Phone: 231-215-0103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004610
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: