Healthcare Provider Details

I. General information

NPI: 1104170760
Provider Name (Legal Business Name): KENNETH E ERICKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 TOWNE SQUARE BLVD NW
ROANOKE VA
24012-1610
US

IV. Provider business mailing address

1337 TOWNE SQUARE BLVD NW
ROANOKE VA
24012-1610
US

V. Phone/Fax

Practice location:
  • Phone: 540-362-2770
  • Fax: 304-324-8308
Mailing address:
  • Phone: 540-362-2770
  • Fax: 304-324-8308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number1866
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: