Healthcare Provider Details

I. General information

NPI: 1346056678
Provider Name (Legal Business Name): KENNY JOSEPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2024
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7106 IVY CHASE WAY NE
ATLANTA GA
30342-4253
US

IV. Provider business mailing address

7106 IVY CHASE WAY NE
ATLANTA GA
30342-4253
US

V. Phone/Fax

Practice location:
  • Phone: 313-200-4543
  • Fax:
Mailing address:
  • Phone: 313-200-4543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: