Provider Demographics
NPI:1225581481
Name:VANTASSEL, KENNETH PERRY
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:PERRY
Last Name:VANTASSEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 WOODFAIR DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-6609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1410 WOODFAIR DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77406-6609
Practice Address - Country:US
Practice Address - Phone:530-651-3022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-24
Last Update Date:2016-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman