Provider Demographics
NPI:1083075212
Name:IHENETU, KENNETH (PHD, DABCC, FACB)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:IHENETU
Suffix:
Gender:M
Credentials:PHD, DABCC, FACB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 DELAWARE AVE, FL1
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054
Mailing Address - Country:US
Mailing Address - Phone:361-944-9554
Mailing Address - Fax:
Practice Address - Street 1:785 DELAWARE AVE FL 1
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-9713
Practice Address - Country:US
Practice Address - Phone:361-944-9554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYIHENK1247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician