Healthcare Provider Details

I. General information

NPI: 1922268788
Provider Name (Legal Business Name): KEVIN P KENNEDY C.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: KEVIN KENNEDY KEVIN KENNEDY CP&O

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 03/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 GARDEN HWY. STE. 900
YUBA CITY CA
95991-7598
US

IV. Provider business mailing address

551 S BOLLING RD
PAHRUMP NV
89048-4642
US

V. Phone/Fax

Practice location:
  • Phone: 530-673-6913
  • Fax: 530-671-6915
Mailing address:
  • Phone: 702-468-2376
  • Fax: 702-823-1336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberABCCP003164BOCC15566
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: