MEDICARE: KENDRA L. MAHAFFEY O.D., INC.

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	5130/T2029	OH

General Provider Information

NPI Number	:	1912009218
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENDRA L. MAHAFFEY O.D., INC.

Provider Business Mailing Address
First Line	:	3057 LOST NATION RD
Second Line	:
City	:	WILLOUGHBY
State	:	OH
Zip	:	44094-7672
Country	:	US
Telephone Number	:	440-942-9315
Fax Number	:	440-942-9374

Provider Business Practice Location Address
First Line	:	34440 VINE ST
Second Line	:
City	:	EASTLAKE
State	:	OH
Zip	:	44095
Country	:	US
Telephone Number	:	440-942-9315
Fax Number	:	440-942-9374

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KENDRA LEA MAHAFFEY
Credential	:	O.D.
Telephone Number	:	440-942-9315

Provider Enumeration Date	:	09/05/2006
Last Update Date	:	08/22/2020

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