Provider Demographics
NPI:1669447249
Name:KENDRICK, EMBRY MAYES (OD)
Entity Type:Individual
Prefix:DR
First Name:EMBRY
Middle Name:MAYES
Last Name:KENDRICK
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:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:GA
Mailing Address - Zip Code:31321-0490
Mailing Address - Country:US
Mailing Address - Phone:912-225-1929
Mailing Address - Fax:912-225-1929
Practice Address - Street 1:1962 OLD GROVELAND RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:GA
Practice Address - Zip Code:31321-3340
Practice Address - Country:US
Practice Address - Phone:912-225-1929
Practice Address - Fax:912-225-1929
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1222152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00728725AMedicaid
GA00728725AMedicaid
GA41ZCBZGMedicare ID - Type Unspecified