Provider Demographics
NPI:1427508258
Name:OPTOMETRY CLINIC OF KENMARE
Entity type:Organization
Organization Name:OPTOMETRY CLINIC OF KENMARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:COLBY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-385-4004
Mailing Address - Street 1:28 2ND ST NW
Mailing Address - Street 2:PO BOX 512
Mailing Address - City:KENMARE
Mailing Address - State:ND
Mailing Address - Zip Code:58746-7114
Mailing Address - Country:US
Mailing Address - Phone:701-385-4004
Mailing Address - Fax:701-385-4005
Practice Address - Street 1:28 2ND ST NW
Practice Address - Street 2:
Practice Address - City:KENMARE
Practice Address - State:ND
Practice Address - Zip Code:58746-7114
Practice Address - Country:US
Practice Address - Phone:701-385-4004
Practice Address - Fax:701-385-4005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND392152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty