=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336166818
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINDA LOU KINDSVATTER OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2006
-----------------------------------------------------
Last Update Date | 07/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 S PONCE DE LEON BLVD STE 4
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32084-6013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-231-8481
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26 JOINER ST
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32084-2863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-488-0401
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1693DT
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4758
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 6657
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------