Healthcare Provider Details

I. General information

NPI: 1225581481
Provider Name (Legal Business Name): KENNETH PERRY VANTASSEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2016
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD
CAMP LEJEUNE NC
28547-2575
US

IV. Provider business mailing address

100 BREWSTER BLVD
CAMP LEJEUNE NC
28547-2575
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-4357
  • Fax:
Mailing address:
  • Phone: 910-450-4357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: