Basic Information
| Provider Information | |||||||||
| NPI: | 1104167345 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENNEDY VISION PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | THE FAMILY EYE SITE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18503 PINES BLVD STE 205 | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330291405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544308330 | ||||||||
| FaxNumber: | 9544303638 | ||||||||
| Practice Location | |||||||||
| Address1: | 12208 PINES BLVD | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330264126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544411165 | ||||||||
| FaxNumber: | 9544410074 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2013 | ||||||||
| LastUpdateDate: | 06/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KENNEDY | ||||||||
| AuthorizedOfficialFirstName: | CALEB | ||||||||
| AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9544308330 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | 06/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC4146 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.