Provider Demographics
NPI:1114901451
Name:DE LUCA, KENNY A (PT)
Entity Type:Individual
Prefix:
First Name:KENNY
Middle Name:A
Last Name:DE LUCA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13567
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-0567
Mailing Address - Country:US
Mailing Address - Phone:501-753-2201
Mailing Address - Fax:501-753-2207
Practice Address - Street 1:9843 MAUMELLE BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72113-7027
Practice Address - Country:US
Practice Address - Phone:501-753-2201
Practice Address - Fax:501-753-2207
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2475225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F332OtherAR BCBS GROUP
AR5W795OtherAR BCBS INDIVIDUAL
AR5F332OtherAR BCBS GROUP
AS5F332Medicare PIN