Provider Demographics
NPI:1609496249
Name:KENNEDY, OMAR (ATC)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10876 PALMS BLVD APT 10
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-5553
Mailing Address - Country:US
Mailing Address - Phone:917-279-0861
Mailing Address - Fax:
Practice Address - Street 1:2560 COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-1005
Practice Address - Country:US
Practice Address - Phone:323-255-5409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer