Provider Demographics
NPI:1295361731
Name:MUNOZ-PORTER, KENNETH ALLEN
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALLEN
Last Name:MUNOZ-PORTER
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:PO BOX 1607
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91017-5607
Mailing Address - Country:US
Mailing Address - Phone:626-817-3367
Mailing Address - Fax:626-415-6770
Practice Address - Street 1:225 S IVY AVE # 1607
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-2835
Practice Address - Country:US
Practice Address - Phone:626-817-3367
Practice Address - Fax:626-415-6770
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA246Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Y00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Health Information