Provider Demographics
NPI:1841321478
Name:KENNEDY, JOHN A (BCO)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:A
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:BCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:150 EL CAMINO REAL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3668
Mailing Address - Country:US
Mailing Address - Phone:714-508-8565
Mailing Address - Fax:714-730-1894
Practice Address - Street 1:150 EL CAMINO REAL
Practice Address - Street 2:SUITE 101
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3668
Practice Address - Country:US
Practice Address - Phone:714-508-8565
Practice Address - Fax:714-730-1894
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADXX00009FMedicaid
CADXX00009FMedicaid