Healthcare Provider Details

I. General information

NPI: 1285103911
Provider Name (Legal Business Name): KENNETH A HUGHES IV LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2018
Last Update Date: 11/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 W FRONT ST
NOME AK
99762-9800
US

IV. Provider business mailing address

318 LESTER BENCH RD.
NOME AK
99762
US

V. Phone/Fax

Practice location:
  • Phone: 907-443-7477
  • Fax:
Mailing address:
  • Phone: 907-443-5130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number121213
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: