Provider Demographics
NPI:1992434393
Name:KENNEDY, BRUCE CLARK JR (LDO)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:CLARK
Last Name:KENNEDY
Suffix:JR
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:805 US HIGHWAY 27 S
Mailing Address - Street 2:
Mailing Address - City:CYNTHIANA
Mailing Address - State:KY
Mailing Address - Zip Code:41031-6888
Mailing Address - Country:US
Mailing Address - Phone:859-234-6190
Mailing Address - Fax:859-234-6190
Practice Address - Street 1:805 US HIGHWAY 27 S
Practice Address - Street 2:
Practice Address - City:CYNTHIANA
Practice Address - State:KY
Practice Address - Zip Code:41031-6888
Practice Address - Country:US
Practice Address - Phone:859-234-6190
Practice Address - Fax:859-234-6190
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY110314156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician