| Doctor Name: | DR. KERRY LEE GRIEBENOW |
| NPI Number: | 1063487072 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | O.D. |
| License Number: | 1666 |
| Business Practice Address: | 105 Northridge Dr New London, WI - 549612703 |
| Business Phone Number: | 9209823711 |
| Business Fax Number: | 9209823009 |
| Mailing Address: | 105 Northridge Dr, P.o. Box 230 NEW LONDON |
| State: | WI |
| Postal Code: | 549612703 |
| Phone Number: | 9209823711 |
| Fax Number: | 9209823009 |
| NPI Enumeration Date: | 02/22/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 152WC0802X |
| License Number: | 1666 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WI |
| Taxonomy Type: | Eye and Vision Services Providers |
| Taxonomy Classification: | Optometrist |
| Taxonomy Specialization: | Corneal and Contact Management |
| Taxonomy Definition: | The professional activities performed by an Optometrist related to the fitting of contact lenses to an eye, ongoing evaluation of the cornea |