Provider Demographics
NPI:1992955611
Name:KENNETH R VAN AMERONGEN OD,PC
Entity type:Organization
Organization Name:KENNETH R VAN AMERONGEN OD,PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:VAN AMERONGEN OD,PC
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:970-667-3445
Mailing Address - Street 1:1209 W EISENHOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-3128
Mailing Address - Country:US
Mailing Address - Phone:970-667-3445
Mailing Address - Fax:970-667-8426
Practice Address - Street 1:1209 W EISENHOWER BLVD
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-3128
Practice Address - Country:US
Practice Address - Phone:970-667-3445
Practice Address - Fax:970-667-8426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1449332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
COT88838Medicare UPIN
CO42123Medicare PIN
CO5304510001Medicare NSC