Healthcare Provider Details

I. General information

NPI: 1205992088
Provider Name (Legal Business Name): RICHARD A KJOME O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 3RD AVE
ANTIGO WI
54409-2044
US

IV. Provider business mailing address

PO BOX 238
ANTIGO WI
54409-0238
US

V. Phone/Fax

Practice location:
  • Phone: 715-623-2180
  • Fax:
Mailing address:
  • Phone: 715-623-2180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1477-035
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: