1407822265 NPI number — LISA A KENNEDY O.D.

Table of content: LISA A KENNEDY O.D. (NPI 1407822265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407822265 NPI number — LISA A KENNEDY O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENNEDY
Provider First Name:
LISA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407822265
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 43366
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35243-0366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-995-2020
Provider Business Mailing Address Fax Number:
205-991-9654

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4515 SOUTHLAKE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35244-3317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-987-2020
Provider Business Practice Location Address Fax Number:
205-988-0588
Provider Enumeration Date:
02/23/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  S-987-TA-572 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: S-987-TA-572 . This is a "AL BOARD OF OPTOMETRY" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".