Provider Demographics
NPI:1275678732
Name:MCKENZIE, KEVIN MICHAEL (LAT, LPTA)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:LAT, LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1319 WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-2445
Mailing Address - Country:US
Mailing Address - Phone:302-575-0550
Mailing Address - Fax:302-657-8373
Practice Address - Street 1:2813 W 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806-1112
Practice Address - Country:US
Practice Address - Phone:302-722-0406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ3-0000118174400000X
DEJ2-0000138246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered174400000XOther Service ProvidersSpecialist
Not Answered246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other