Healthcare Provider Details

I. General information

NPI: 1497089130
Provider Name (Legal Business Name): KENNETH WAYNE KEITH JR. M.L.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 09/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ZORN AVE
LOUISVILLE KY
40206-1433
US

IV. Provider business mailing address

7806 FLOYDSBURG RD
CRESTWOOD KY
40014-9294
US

V. Phone/Fax

Practice location:
  • Phone: 502-287-5046
  • Fax:
Mailing address:
  • Phone: 502-243-9429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number244276
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: