Healthcare Provider Details

I. General information

NPI: 1053662361
Provider Name (Legal Business Name): KENNETH GARRETT DUGGER ATC, PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2012
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5625 PEARL DR STE 100
EVANSVILLE IN
47712-8106
US

IV. Provider business mailing address

415 CROSSLAKE DR STE B
EVANSVILLE IN
47715-8272
US

V. Phone/Fax

Practice location:
  • Phone: 812-759-7493
  • Fax:
Mailing address:
  • Phone: 812-476-0409
  • Fax: 812-476-1016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06006142A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36001954A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: