Healthcare Provider Details

I. General information

NPI: 1326445743
Provider Name (Legal Business Name): KENNETH DEANGELIS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2014
Last Update Date: 12/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 169TH ST
HAMMOND IN
46323-2068
US

IV. Provider business mailing address

400 N LAKE PARK AVE APT T2N
HOBART IN
46342-3031
US

V. Phone/Fax

Practice location:
  • Phone: 989-903-5267
  • Fax: 219-989-2558
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36002052A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: