Basic Information
| Provider Information | |||||||||
| NPI: | 1811995418 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUYKENDALL | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 839 N NOLAN RIVER RD | ||||||||
| Address2: | |||||||||
| City: | CLEBURNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760337001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176452411 | ||||||||
| FaxNumber: | 8176453447 | ||||||||
| Practice Location | |||||||||
| Address1: | 839 N NOLAN RIVER RD | ||||||||
| Address2: | |||||||||
| City: | CLEBURNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760337001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176452411 | ||||||||
| FaxNumber: | 8176453447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 08/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 5641TG | TX | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0463630-01 | 05 | TX | MEDICAID | 22510 | 01 | TX | OPTICARE | OTHER | 80183Q | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |