Healthcare Provider Details

I. General information

NPI: 1568412344
Provider Name (Legal Business Name): KENNETH ANTHONY YEAGER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2304 W PARKER RD
GREENVILLE SC
29617-2123
US

IV. Provider business mailing address

2304W PARKER RD
GREENVILLE SC
29617-2123
US

V. Phone/Fax

Practice location:
  • Phone: 864-246-0964
  • Fax:
Mailing address:
  • Phone: 864-246-0964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1027
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: