Healthcare Provider Details

I. General information

NPI: 1689041287
Provider Name (Legal Business Name): KENNETH YOUNG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2015
Last Update Date: 08/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3838 50TH ST
LUBBOCK TX
79413-3808
US

IV. Provider business mailing address

3838 50TH ST
LUBBOCK TX
79413-3808
US

V. Phone/Fax

Practice location:
  • Phone: 806-792-5522
  • Fax: 806-785-7582
Mailing address:
  • Phone: 806-792-5522
  • Fax: 806-785-7582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1265309
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: