Healthcare Provider Details

I. General information

NPI: 1669447249
Provider Name (Legal Business Name): EMBRY MAYES KENDRICK OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 03/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1962 OLD GROVELAND RD
PEMBROKE GA
31321-3340
US

IV. Provider business mailing address

PO BOX 490
PEMBROKE GA
31321-0490
US

V. Phone/Fax

Practice location:
  • Phone: 912-225-1929
  • Fax: 912-225-1929
Mailing address:
  • Phone: 912-225-1929
  • Fax: 912-225-1929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1222
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: