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General NPI Number Information
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NPI Number | 1942755160
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Entity Type | Organization
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Legal Business Name | KENS UNITED OPTICAL
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Dates
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Enumeration Date | 08/17/2016
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Last Update Date | 05/11/2017
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Provider Practice Location Address
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Address Line | 225 BLANDING BLVD
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City | ORANGE PARK
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State | FL
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Zip | 32073-3357
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Country | US
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Telephone | 904-276-4611
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Fax |
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Provider Business Mailing Address
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Address Line | 225 BLANDING BLVD
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City | ORANGE PARK
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State | FL
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Zip | 32073-3357
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Country | US
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Telephone | 904-276-4611
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Fax |
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Authorized Official
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Title or Position | OWNER/ DISPENSING OPTICIAN
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Name | MR. KENNETH LAWRENCE GROLEAU
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Credential | DO
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Telephone | 904-276-4611
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | DO3062
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License Number State | FL
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