Provider Demographics
NPI:1700889532
Name:KENDALL, KENNETH R (OD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:KENDALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 E STOWELL RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-7001
Mailing Address - Country:US
Mailing Address - Phone:805-925-2637
Mailing Address - Fax:805-347-0033
Practice Address - Street 1:425 W CENTRAL AVE STE 102
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-2806
Practice Address - Country:US
Practice Address - Phone:805-736-2020
Practice Address - Fax:805-737-1733
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT9482T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1312330002OtherMEDICARE DMERC
CAP00190674OtherMEDICARE RAILROAD
CASD0094820Medicaid
CASD0094820Medicaid
CAU02320Medicare UPIN