Provider Demographics
NPI:1871561795
Name:KENNEDY, SCOTT
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-1821
Mailing Address - Country:US
Mailing Address - Phone:605-717-1100
Mailing Address - Fax:
Practice Address - Street 1:1230 NORTH AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-3028
Practice Address - Country:US
Practice Address - Phone:605-642-4656
Practice Address - Fax:605-722-5622
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD592152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9201370Medicaid
SD9201370Medicaid
SDS2989Medicare ID - Type Unspecified