Provider Demographics
NPI:1083920391
Name:KENNI RAGAVAN, VENKATESH
Entity Type:Individual
Prefix:MR
First Name:VENKATESH
Middle Name:
Last Name:KENNI RAGAVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1032 S LINDEN RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3458
Mailing Address - Country:US
Mailing Address - Phone:810-733-3833
Mailing Address - Fax:810-733-1072
Practice Address - Street 1:1032 S LINDEN RD
Practice Address - Street 2:SUITE A
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3458
Practice Address - Country:US
Practice Address - Phone:810-733-3833
Practice Address - Fax:810-733-1072
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014652225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist