=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912071127
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENNEDY & PERKINS INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2006
-----------------------------------------------------
Last Update Date | 03/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 80 WHITNEY AVE
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06510-1217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-624-3145
-----------------------------------------------------
Fax | 203-867-8733
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 80 WHITNEY AVE
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06510-1217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-624-3145
-----------------------------------------------------
Fax | 203-867-8733
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE-PRESIDENT
-----------------------------------------------------
Name | MR. RICHARD L. KENNEDY JR.
-----------------------------------------------------
Credential | LICENSED OPTICIAN
-----------------------------------------------------
Telephone | 203-624-3145
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | 001178
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 001178
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------