Provider Demographics
NPI:1104957679
Name:KEITH A KOHORST OD
Entity type:Organization
Organization Name:KEITH A KOHORST OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:KOHORST
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:702-456-1882
Mailing Address - Street 1:2480 E TOMPKINS AVE
Mailing Address - Street 2:STE #101
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121
Mailing Address - Country:US
Mailing Address - Phone:702-456-1882
Mailing Address - Fax:702-456-6083
Practice Address - Street 1:2480 E TOMPKINS AVE
Practice Address - Street 2:STE #101
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121
Practice Address - Country:US
Practice Address - Phone:702-456-1882
Practice Address - Fax:702-456-6083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVOD253152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty