Healthcare Provider Details

I. General information

NPI: 1306906060
Provider Name (Legal Business Name): KENNETH JASON PROEFROCK NMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14991 W BELL RD
SURPRISE AZ
85374-3874
US

IV. Provider business mailing address

14991 W BELL RD
SURPRISE AZ
85374-3874
US

V. Phone/Fax

Practice location:
  • Phone: 623-977-0077
  • Fax: 623-977-0057
Mailing address:
  • Phone: 623-977-0077
  • Fax: 623-977-0057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number96-481
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number96-481
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number96-481
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number96-481
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: