Healthcare Provider Details

I. General information

NPI: 1972098184
Provider Name (Legal Business Name): KENDERICK RENARD STREET JR. IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2018
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WAHOO AVE BLDG 449
GROTON CT
06349-2324
US

IV. Provider business mailing address

474 BURNINGTREE DR
GROTON CT
06340-3108
US

V. Phone/Fax

Practice location:
  • Phone: 860-694-4123
  • Fax:
Mailing address:
  • Phone: 912-331-3110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number1972098184
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number1972098184
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: