Healthcare Provider Details

I. General information

NPI: 1134438419
Provider Name (Legal Business Name): KENTON DELL KIRBY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2010
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date: 12/21/2011
Reactivation Date: 11/28/2018

III. Provider practice location address

1202 3RD ST W
ROUNDUP MT
59072-1816
US

IV. Provider business mailing address

1202 3RD ST W
ROUNDUP MT
59072-1816
US

V. Phone/Fax

Practice location:
  • Phone: 406-323-2301
  • Fax:
Mailing address:
  • Phone: 406-323-2301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1064
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: