Healthcare Provider Details

I. General information

NPI: 1881674752
Provider Name (Legal Business Name): STEVEN CLARK KINNETT M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 11/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 N GREENWOOD ST SUITE 406
PUEBLO CO
81003-2644
US

IV. Provider business mailing address

1619 N GREENWOOD ST SUITE 406
PUEBLO CO
81003-2644
US

V. Phone/Fax

Practice location:
  • Phone: 719-584-7310
  • Fax:
Mailing address:
  • Phone: 719-584-7310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number28014
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: