Healthcare Provider Details

I. General information

NPI: 1225029697
Provider Name (Legal Business Name): KEVIN LANGESON KISH OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 10/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

352 S MAIN ST BOX 38
ZUMBROTA MN
55992-0038
US

IV. Provider business mailing address

352 S MAIN ST BOX 38
ZUMBROTA MN
55992-0038
US

V. Phone/Fax

Practice location:
  • Phone: 507-732-7630
  • Fax: 507-732-5401
Mailing address:
  • Phone: 507-732-7630
  • Fax: 507-732-5401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1673
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: