Provider Demographics
NPI:1912009218
Name:KENDRA L. MAHAFFEY O.D., INC.
Entity Type:Organization
Organization Name:KENDRA L. MAHAFFEY O.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:MAHAFFEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:440-942-9315
Mailing Address - Street 1:3057 LOST NATION RD
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-7672
Mailing Address - Country:US
Mailing Address - Phone:440-942-9315
Mailing Address - Fax:440-942-9374
Practice Address - Street 1:34440 VINE ST
Practice Address - Street 2:
Practice Address - City:EASTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44095
Practice Address - Country:US
Practice Address - Phone:440-942-9315
Practice Address - Fax:440-942-9374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5130/T2029152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty