Provider Demographics
NPI:1093135469
Name:PHELPS, KENNETH SCOTT (LAC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:SCOTT
Last Name:PHELPS
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 1:30452 PRESTWICK AVE
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-7328
Mailing Address - Country:US
Mailing Address - Phone:415-654-4543
Mailing Address - Fax:
Practice Address - Street 1:13939 E 14TH ST STE 150
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2601
Practice Address - Country:US
Practice Address - Phone:510-343-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 17225171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist