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General NPI Number Information
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NPI Number | 1740979525
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Entity Type | Individual
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Provider Name | MR. MACK HENRY KENNEY JR.
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Gender | Male
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Dates
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Enumeration Date | 05/05/2023
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Last Update Date | 05/05/2023
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Provider Practice Location Address
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Address Line | 406 ROYAL CREST CIR
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City | KATHLEEN
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State | GA
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Zip | 31047-2169
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Country | US
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Telephone | 770-374-7110
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Fax |
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Provider Business Mailing Address
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Address Line | 103 COLLETON DR
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City | ATHENS
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State | GA
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Zip | 30606-7831
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Country | US
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Telephone | 706-206-2964
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172A00000X
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Taxonomy Name | Driver
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License Number | 052745615
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License Number State | GA
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