Provider Demographics
NPI:1912119942
Name:KENNEDY & YOUNG OPTOMETRY
Entity Type:Organization
Organization Name:KENNEDY & YOUNG OPTOMETRY
Other - Org Name:VALLEY OPTOMETRIC GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TRISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-527-6640
Mailing Address - Street 1:1401 SYLVAN AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-1367
Mailing Address - Country:US
Mailing Address - Phone:209-527-6640
Mailing Address - Fax:209-527-5489
Practice Address - Street 1:1401 SYLVAN AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1367
Practice Address - Country:US
Practice Address - Phone:209-527-6640
Practice Address - Fax:209-527-5489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5320840001Medicare NSC
CAZZZ00062ZMedicare PIN