Healthcare Provider Details

I. General information

NPI: 1487047312
Provider Name (Legal Business Name): KENNETH RAINEY II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2015
Last Update Date: 03/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3077 MAYFIELD RD
CLEVELAND HEIGHTS OH
44118-1720
US

IV. Provider business mailing address

3077 MAYFIELD RD
CLEVELAND HEIGHTS OH
44118-1720
US

V. Phone/Fax

Practice location:
  • Phone: 216-458-2458
  • Fax:
Mailing address:
  • Phone: 216-458-2458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WV0202X
TaxonomyVehicle Modifications Contractor
License NumberND003878
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: