Provider Demographics
NPI:1083285696
Name:MCKENNA, GEORGE HENRY III (LMT)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:HENRY
Last Name:MCKENNA
Suffix:III
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9702 UNIVERSAL BLVD APT 325
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-8741
Mailing Address - Country:US
Mailing Address - Phone:401-301-9674
Mailing Address - Fax:
Practice Address - Street 1:7345 W SAND LAKE RD STE 226
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-5252
Practice Address - Country:US
Practice Address - Phone:401-301-9674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA82847225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist