Healthcare Provider Details

I. General information

NPI: 1528033909
Provider Name (Legal Business Name): KENSINGTON VALLEY ORTHOTIC & SPORTS SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10020 PROFESSIONAL CANTER DR.
HAMBURG MI
48139-0215
US

IV. Provider business mailing address

PO BOX 215
HAMBURG MI
48139-0215
US

V. Phone/Fax

Practice location:
  • Phone: 810-231-6905
  • Fax: 810-231-6906
Mailing address:
  • Phone: 810-231-6905
  • Fax: 801-231-6906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL QUENTIN MINERT
Title or Position: PRESIDENT/OWNER
Credential: C.O.
Phone: 810-231-6905