=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457713794
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT LEE KENT JR. RN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2016
-----------------------------------------------------
Last Update Date | 03/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2240 EAST WINROW AVENUE
-----------------------------------------------------
City | FORT HUACHUCA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-533-9026
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 657 HAYES DR
-----------------------------------------------------
City | SIERRA VISTA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85635-4448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-243-3753
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN119404
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------