Provider Demographics
NPI:1003969122
Name:MORRIS, KENNETH DOUGLAS (LAC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:DOUGLAS
Last Name:MORRIS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 MAPLETON AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-1560
Mailing Address - Country:US
Mailing Address - Phone:415-254-4240
Mailing Address - Fax:
Practice Address - Street 1:735 MAPLETON AVE STE 203
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-1560
Practice Address - Country:US
Practice Address - Phone:302-396-6880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 3101171100000X
CA8691171100000X
DECT-0010015171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0031010Medicaid