Healthcare Provider Details

I. General information

NPI: 1801534268
Provider Name (Legal Business Name): KENNEDY REED OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2022
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5091 W BETHEL AVE STE 150
MUNCIE IN
47304-8511
US

IV. Provider business mailing address

9202 N MERIDIAN ST
INDIANAPOLIS IN
46260-1800
US

V. Phone/Fax

Practice location:
  • Phone: 765-286-8888
  • Fax: 765-747-7962
Mailing address:
  • Phone: 317-841-2020
  • Fax: 317-570-7433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18004384A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT.007056
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: