Healthcare Provider Details

I. General information

NPI: 1326136193
Provider Name (Legal Business Name): KENNETH RAY MITCHELL JR. MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COMDT CG-1122 U S COAST GUARD 2100 2ND ST SW, SUITE 5314
WASHINGTON DC
20593-0001
US

IV. Provider business mailing address

COMDT CG-1122 U S COAST GUARD 2100 2ND ST SW, SUITE 5314
WASHINGTON DC
20593-0001
US

V. Phone/Fax

Practice location:
  • Phone: 757-856-2230
  • Fax:
Mailing address:
  • Phone: 757-856-2230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: