Basic Information
| Provider Information | |||||||||
| NPI: | 1215503560 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DORN | ||||||||
| FirstName: | KIRSTEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SULLIVAN | ||||||||
| OtherFirstName: | KIRSTEN | ||||||||
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| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 111 E 4TH ST STE 440 | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184629818 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2005 COURT ST | ||||||||
| Address2: | |||||||||
| City: | BEATRICE | ||||||||
| State: | NE | ||||||||
| PostalCode: | 683103210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4022234098 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2021 | ||||||||
| LastUpdateDate: | 01/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1534 | NE | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.