Provider Demographics
NPI:1033203963
Name:KENNEDY VISION HEALTH CENTER, LLC
Entity Type:Organization
Organization Name:KENNEDY VISION HEALTH CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:TRAVERSE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:763-545-8850
Mailing Address - Street 1:10600 OLD COUNTY ROAD 15
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-6210
Mailing Address - Country:US
Mailing Address - Phone:763-545-8850
Mailing Address - Fax:763-544-1257
Practice Address - Street 1:10600 OLD COUNTY ROAD 15
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-6210
Practice Address - Country:US
Practice Address - Phone:763-545-8850
Practice Address - Fax:763-544-1257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01040808OtherPREFERRED ONE
MN417R4KEOtherBCBS
MNDB1166OtherRAILROAD MEDICARE
MN170285OtherUCARE
MN99240OtherHEALTH PARTNERS
MN2115782OtherMEDICA
MN620020600Medicaid
MN620020600Medicaid