Basic Information
| Provider Information | |||||||||
| NPI: | 1215367917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KINGSOLVER | ||||||||
| FirstName: | TRACIE | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2920 GLENDALE MILFORD RD STE 220 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452413131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135573669 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5303 GLENWAY AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452383706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139229000 | ||||||||
| FaxNumber: | 5139224050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2013 | ||||||||
| LastUpdateDate: | 01/08/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 6248 | OH | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 6248 | 01 | OH | OHIO | OTHER |