Provider Demographics
NPI:1538488358
Name:DR. KENNETH LORD, PC
Entity Type:Organization
Organization Name:DR. KENNETH LORD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF RETAIL
Authorized Official - Prefix:
Authorized Official - First Name:STACIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-327-6215
Mailing Address - Street 1:6987 N ORACLE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-4224
Mailing Address - Country:US
Mailing Address - Phone:520-297-2501
Mailing Address - Fax:
Practice Address - Street 1:6987 N ORACLE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-4224
Practice Address - Country:US
Practice Address - Phone:520-297-2501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0486152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ049777Medicaid
AZT78874Medicare UPIN