Healthcare Provider Details

I. General information

NPI: 1215349477
Provider Name (Legal Business Name): KENNETH HOOPER JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2014
Last Update Date: 05/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 MAIN
LANDER WY
82514-0638
US

IV. Provider business mailing address

345 MAIN PO BOX 638
LANDER WY
82514-0638
US

V. Phone/Fax

Practice location:
  • Phone: 513-460-7241
  • Fax: 307-332-0131
Mailing address:
  • Phone: 513-460-7241
  • Fax: 307-332-0131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License NumberGN-2095-10
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: