Provider Demographics
NPI:1134482730
Name:MENARD, KEVIN ANTHONY (LAC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ANTHONY
Last Name:MENARD
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:PO BOX 2271
Mailing Address - Street 2:
Mailing Address - City:SAG HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11963-0112
Mailing Address - Country:US
Mailing Address - Phone:917-689-2153
Mailing Address - Fax:
Practice Address - Street 1:39 DIVISION ST
Practice Address - Street 2:
Practice Address - City:SAG HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11963-3156
Practice Address - Country:US
Practice Address - Phone:917-689-2153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004842-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist