Provider Demographics
NPI:1154313633
Name:KENNEDY, RICHARD (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 ARMORY RD STE C
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-5478
Mailing Address - Country:US
Mailing Address - Phone:760-252-7518
Mailing Address - Fax:760-252-7510
Practice Address - Street 1:945 ARMORY RD STE C
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-5478
Practice Address - Country:US
Practice Address - Phone:760-252-7518
Practice Address - Fax:760-252-7510
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5803T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist