Provider Demographics
NPI:1538511837
Name:KENNEDY, MALLORY ADELE (OD)
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:ADELE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7379 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-4547
Mailing Address - Country:US
Mailing Address - Phone:951-684-7822
Mailing Address - Fax:951-977-8075
Practice Address - Street 1:7379 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-4547
Practice Address - Country:US
Practice Address - Phone:951-684-7822
Practice Address - Fax:951-977-8075
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33508TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist