Healthcare Provider Details

I. General information

NPI: 1225476013
Provider Name (Legal Business Name): KENDAL LEWIS GENO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2013
Last Update Date: 07/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E LOCKLING ST
BROOKFIELD MO
64628-2367
US

IV. Provider business mailing address

125 E LOCKLING AVE
BROOKFIELD MO
64628
US

V. Phone/Fax

Practice location:
  • Phone: 660-258-8237
  • Fax:
Mailing address:
  • Phone: 660-258-8237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2013017659
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: