Provider Demographics
NPI:1285603381
Name:KINDERKNECHT, TRAVIS L (OD)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:L
Last Name:KINDERKNECHT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:QUINTER
Mailing Address - State:KS
Mailing Address - Zip Code:67752-0307
Mailing Address - Country:US
Mailing Address - Phone:785-754-2494
Mailing Address - Fax:
Practice Address - Street 1:1201 CASTLE ROCK RD
Practice Address - Street 2:
Practice Address - City:QUINTER
Practice Address - State:KS
Practice Address - Zip Code:67752-9516
Practice Address - Country:US
Practice Address - Phone:785-754-2494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1554152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U76466Medicare UPIN
KS650703Medicare ID - Type UnspecifiedQUINTER KS PRACTICE
KS1297690001Medicare NSC
KS053998Medicare ID - Type UnspecifiedEYE SPECIALISTS PRACTICE