Healthcare Provider Details

I. General information

NPI: 1275705071
Provider Name (Legal Business Name): MR. KENNETH O HARDEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 NE 10TH AVE SUITE #10
GAINESVILLE FL
32601-2300
US

IV. Provider business mailing address

102 NE 10TH AVE SUITE #10
GAINESVILLE FL
32601-2300
US

V. Phone/Fax

Practice location:
  • Phone: 352-373-9233
  • Fax: 352-379-9530
Mailing address:
  • Phone: 352-373-9233
  • Fax: 352-379-9530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License NumberF593675698001
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: