Provider Demographics
NPI:1013385806
Name:KENISTON, NATHAN (DPT)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:KENISTON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6809 AMBERLY ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-3108
Mailing Address - Country:US
Mailing Address - Phone:541-821-1763
Mailing Address - Fax:
Practice Address - Street 1:5886 VENTURE PARK DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-1848
Practice Address - Country:US
Practice Address - Phone:269-375-4737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR63210225100000X
MI5501017367225100000X
IL070022218225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist