Healthcare Provider Details

I. General information

NPI: 1275975443
Provider Name (Legal Business Name): KENNETH E HERRON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2013
Last Update Date: 07/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 ELECTRIC AVE
PORT HURON MI
48060-8127
US

IV. Provider business mailing address

1010 POPLAR ST
PORT HURON MI
48060-3654
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-8900
  • Fax:
Mailing address:
  • Phone: 810-300-8448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: