Healthcare Provider Details

I. General information

NPI: 1255874145
Provider Name (Legal Business Name): KENNETH GLENN LAIN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2016
Last Update Date: 11/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4351 RIDGEMONT DR STE C
ABILENE TX
79606-8747
US

IV. Provider business mailing address

4351 RIDGEMONT DR STE C
ABILENE TX
79606-8747
US

V. Phone/Fax

Practice location:
  • Phone: 325-668-7591
  • Fax: 325-698-4547
Mailing address:
  • Phone: 325-668-7591
  • Fax: 325-698-4547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1001274
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: