MEDICARE: DR. KENDALL CLARK MULLINS O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	S-779-TA-718	AL
2	152W00000X	Optometrist	OPT001400	GA

General Provider Information

NPI Number	:	1144364043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENDALL CLARK MULLINS O.D.

Provider Business Mailing Address
First Line	:	70 COUNTY ROAD 941
Second Line	:
City	:	CLANTON
State	:	AL
Zip	:	35045-7979
Country	:	US
Telephone Number	:	205-585-6461
Fax Number	:

Provider Business Practice Location Address
First Line	:	9220 MARNE RD
Second Line	:
City	:	FORT MOORE
State	:	GA
Zip	:	31905-5515
Country	:	US
Telephone Number	:	706-682-3938
Fax Number	:	706-682-3931

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2007
Last Update Date	:	05/23/2024

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