Provider Demographics
NPI:1154470193
Name:MANDLER, KENNETH ALAN (CO CERTIFIED ORTHO)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ALAN
Last Name:MANDLER
Suffix:
Gender:M
Credentials:CO CERTIFIED ORTHO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 N HOMESTEAD DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-7580
Mailing Address - Country:US
Mailing Address - Phone:509-389-4783
Mailing Address - Fax:
Practice Address - Street 1:509 N HOMESTEAD DR
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-7580
Practice Address - Country:US
Practice Address - Phone:509-389-4783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000466222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist