Healthcare Provider Details

I. General information

NPI: 1437402013
Provider Name (Legal Business Name): KENNETH D WARREN DPM PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 09/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 BERRY CT
KENNEBUNK ME
04043-6812
US

IV. Provider business mailing address

2 BERRY CT
KENNEBUNK ME
04043-6812
US

V. Phone/Fax

Practice location:
  • Phone: 207-985-9888
  • Fax: 207-985-3488
Mailing address:
  • Phone: 207-985-9888
  • Fax: 207-985-3488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number1084
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number1880
License Number StateTX

VIII. Authorized Official

Name: DR. KENNETH WARREN JR.
Title or Position: SOLE MEMBER
Credential: DPM
Phone: 216-577-7754