=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205617776
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THORNAPPLE EYECARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2023
-----------------------------------------------------
Last Update Date | 12/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4624 N M 37 HWY
-----------------------------------------------------
City | MIDDLEVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49333-8162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-213-8108
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5098 RAVINE DR
-----------------------------------------------------
City | MIDDLEVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49333-8482
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DOCTOR
-----------------------------------------------------
Name | JEFFREY KENYON
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 269-213-8108
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------