Healthcare Provider Details

I. General information

NPI: 1831219260
Provider Name (Legal Business Name): KENN J KOSTELNIK OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1518 E BATTLEFIELD ST
SPRINGFIELD MO
65804-3704
US

IV. Provider business mailing address

1518 E BATTLEFIELD ST
SPRINGFIELD MO
65804-3704
US

V. Phone/Fax

Practice location:
  • Phone: 417-881-5530
  • Fax: 417-889-4071
Mailing address:
  • Phone: 417-881-5530
  • Fax: 417-889-4071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTO2395
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: