Healthcare Provider Details

I. General information

NPI: 1679195614
Provider Name (Legal Business Name): KENNAN DALE RICHARDS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3325 POCAHONTAS RD
BAKER CITY OR
97814-1464
US

IV. Provider business mailing address

3340 E GOLDSTONE DR
MERIDIAN ID
83642-1026
US

V. Phone/Fax

Practice location:
  • Phone: 541-523-1797
  • Fax: 541-523-1799
Mailing address:
  • Phone: 208-367-5170
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDO214758
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number7287
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: