Healthcare Provider Details

I. General information

NPI: 1548590383
Provider Name (Legal Business Name): KENTON A KENNEDY PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2009
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14910 MAIN ST
ALACHUA FL
32615-8591
US

IV. Provider business mailing address

717 NW 29TH PL
GAINESVILLE FL
32609-2962
US

V. Phone/Fax

Practice location:
  • Phone: 386-462-0940
  • Fax:
Mailing address:
  • Phone: 352-271-5612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA108178
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA21967
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: