Healthcare Provider Details

I. General information

NPI: 1558779876
Provider Name (Legal Business Name): KENNETH-ALBERT FABABAER VALENZUELA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2014
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 VILLAGE RD
NEOSHO MO
64850-9076
US

IV. Provider business mailing address

8477 S SUNCOAST BLVD
HOMOSASSA FL
34446-5028
US

V. Phone/Fax

Practice location:
  • Phone: 800-381-0822
  • Fax:
Mailing address:
  • Phone: 800-381-0822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070020735
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberJ1-0003168
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: