Healthcare Provider Details

I. General information

NPI: 1518951896
Provider Name (Legal Business Name): KENNY JOE MANION MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 S L ROGER WELLS BLVD
GLASGOW KY
42141-1191
US

IV. Provider business mailing address

411 S L ROGER WELLS BLVD
GLASGOW KY
42141-1191
US

V. Phone/Fax

Practice location:
  • Phone: 270-651-7796
  • Fax: 270-651-7074
Mailing address:
  • Phone: 270-651-7796
  • Fax: 270-651-7074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24806
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: