Healthcare Provider Details

I. General information

NPI: 1336495704
Provider Name (Legal Business Name): GEORGE KENNEDY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2012
Last Update Date: 10/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 LOWES
CUNNINGHAM KY
42035
US

IV. Provider business mailing address

2050 LOWES
CUNNINGHAM KY
42035
US

V. Phone/Fax

Practice location:
  • Phone: 270-674-5654
  • Fax:
Mailing address:
  • Phone: 270-674-5654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: