Healthcare Provider Details

I. General information

NPI: 1356524011
Provider Name (Legal Business Name): KENMORE EYECARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 02/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 N TELEPHONE RD
MOORE OK
73160-4938
US

IV. Provider business mailing address

513 N TELEPHONE RD
MOORE OK
73160-4938
US

V. Phone/Fax

Practice location:
  • Phone: 405-799-3030
  • Fax: 405-799-3737
Mailing address:
  • Phone: 405-799-3030
  • Fax: 405-799-3737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2366
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number2366
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number2366
License Number StateOK

VIII. Authorized Official

Name: DR. TODD ALAN KENMORE
Title or Position: PRESIDENT
Credential: O.D.
Phone: 405-799-3030