Healthcare Provider Details

I. General information

NPI: 1548583172
Provider Name (Legal Business Name): CHARLES REGGIE KENNEDY SR. CERTIFIED ORTHOTIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2010
Last Update Date: 03/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 LAKELAND DR
JACKSON MS
39216-4611
US

IV. Provider business mailing address

503 CEDAR ST
MIZE MS
39116-5572
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-4844
  • Fax:
Mailing address:
  • Phone: 601-733-2327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberC0004097
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: