Provider Demographics
NPI:1457910861
Name:KENNEDY, BAILEY R (OD)
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:R
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 FM 1189 STE 106-107
Mailing Address - Street 2:
Mailing Address - City:MILLSAP
Mailing Address - State:TX
Mailing Address - Zip Code:76066-3545
Mailing Address - Country:US
Mailing Address - Phone:817-406-2996
Mailing Address - Fax:
Practice Address - Street 1:1120 FM 1189 STE 106
Practice Address - Street 2:
Practice Address - City:MILLSAP
Practice Address - State:TX
Practice Address - Zip Code:76066-3546
Practice Address - Country:US
Practice Address - Phone:817-771-0241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9669T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist