Provider Demographics
NPI:1164121752
Name:RIVES, KENDALL ANDY (PT)
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:ANDY
Last Name:RIVES
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 1:5703 GULF TECH DR
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-8238
Mailing Address - Country:US
Mailing Address - Phone:228-875-5447
Mailing Address - Fax:866-404-9501
Practice Address - Street 1:7521 OLD CANTON RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-8669
Practice Address - Country:US
Practice Address - Phone:601-856-8041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist