Healthcare Provider Details

I. General information

NPI: 1669231262
Provider Name (Legal Business Name): KAITLIN ACKINCLOSE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2024
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3039 MADISON RD
CINCINNATI OH
45209-1709
US

IV. Provider business mailing address

265 N LIBERTY ST
POWELL OH
43065-8870
US

V. Phone/Fax

Practice location:
  • Phone: 513-651-4005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT.007286
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: