Healthcare Provider Details

I. General information

NPI: 1013087063
Provider Name (Legal Business Name): JOSEPH A KENNEDY OTHER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 E LINCOLN RD
IDABEL OK
74745-7337
US

IV. Provider business mailing address

107 MILES ST
BROKEN BOW OK
74728-4507
US

V. Phone/Fax

Practice location:
  • Phone: 580-286-2600
  • Fax: 580-286-1107
Mailing address:
  • Phone: 580-236-5261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1117
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: