Provider Demographics
NPI:1447327432
Name:BROWN, KENNETH L (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:L
Last Name:BROWN
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:DR
Other - First Name:BRIAN
Other - Middle Name:
Other - Last Name:WEAVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:18110 W BLUEMOUND RD STOP 3
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-2917
Mailing Address - Country:US
Mailing Address - Phone:262-796-2020
Mailing Address - Fax:262-796-0504
Practice Address - Street 1:18110 W BLUEMOUND RD STOP 3
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2917
Practice Address - Country:US
Practice Address - Phone:262-796-2020
Practice Address - Fax:262-796-0504
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI2800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist