Healthcare Provider Details

I. General information

NPI: 1053515148
Provider Name (Legal Business Name): KESNEL THEUS D.O.M
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4845 N DIXIE HWY
POMPANO BEACH FL
33064-4861
US

IV. Provider business mailing address

3513 PALAIS TER
WELLINGTON FL
33467-8063
US

V. Phone/Fax

Practice location:
  • Phone: 954-429-0223
  • Fax: 954-429-1063
Mailing address:
  • Phone: 561-929-7711
  • Fax: 954-429-0223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP 2382
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: