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General NPI Number Information
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NPI Number | 1811108608
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Entity Type | Organization
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Legal Business Name | PRO OF KENNETT, INC.
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Dates
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Enumeration Date | 05/24/2007
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Last Update Date | 11/15/2007
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Provider Practice Location Address
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Address Line | 306 RECOVERY RD
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City | KENNETT
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State | MO
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Zip | 63857-3267
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Country | US
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Telephone | 573-888-9190
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Fax | 573-888-9404
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Provider Business Mailing Address
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Address Line | 306 RECOVERY RD
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City | KENNETT
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State | MO
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Zip | 63857-3267
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Country | US
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Telephone | 573-888-9190
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Fax | 573-888-9404
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. TENA R. VANDEVENTER
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Credential |
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Telephone | 573-888-9190
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 02042
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 01506
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License Number State | MO
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Taxonomy #3
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 107027
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License Number State | MO
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Taxonomy #4
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | R0582
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License Number State | MO
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