Healthcare Provider Details

I. General information

NPI: 1538272042
Provider Name (Legal Business Name): MR. KENNETH L CALDWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 HURON AVE
PORT HURON MI
48060-3822
US

IV. Provider business mailing address

230 HURON AVE
PORT HURON MI
48060-3822
US

V. Phone/Fax

Practice location:
  • Phone: 810-966-4484
  • Fax: 810-985-9498
Mailing address:
  • Phone: 810-966-4484
  • Fax: 810-985-9498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: