MEDICARE: KENNETH KINCHLOE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247200000X	Other Technician

General Provider Information

NPI Number	:	1740734904
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH KINCHLOE

Provider Business Mailing Address
First Line	:	2511 WEDGLEA DR
Second Line	:	APT. 223
City	:	DALLAS
State	:	TX
Zip	:	75211-2037
Country	:	US
Telephone Number	:	313-502-6333
Fax Number	:

Provider Business Practice Location Address
First Line	:	2511 WEDGLEA DR
Second Line	:	APT. 223
City	:	DALLAS
State	:	TX
Zip	:	75211-2037
Country	:	US
Telephone Number	:	313-502-6333
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2016
Last Update Date	:	08/05/2016

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Directions to “ KENNETH KINCHLOE ” Practice Location

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