Healthcare Provider Details

I. General information

NPI: 1629511415
Provider Name (Legal Business Name): KENNETT PEDIATRICS AND ASOLESCENTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 11/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 TEACO RD
KENNETT MO
63857-3236
US

IV. Provider business mailing address

211 TEACO RD
KENNETT MO
63857-3236
US

V. Phone/Fax

Practice location:
  • Phone: 573-888-0001
  • Fax: 573-888-0006
Mailing address:
  • Phone: 573-888-0001
  • Fax: 573-888-0006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: AMELIA D LEDBETTER
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 573-335-4715