Healthcare Provider Details

I. General information

NPI: 1982949913
Provider Name (Legal Business Name): KENNETH REPP PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2012
Last Update Date: 12/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14800 W MOUNTAIN VIEW BLVD SUITE 260
SURPRISE AZ
85374-4795
US

IV. Provider business mailing address

14800 W MOUNTAIN VIEW BLVD SUITE 260
SURPRISE AZ
85374-4795
US

V. Phone/Fax

Practice location:
  • Phone: 623-556-5013
  • Fax: 623-556-9290
Mailing address:
  • Phone: 623-556-5013
  • Fax: 623-556-9290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5491A
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: