Provider Demographics
NPI:1295855112
Name:KENNEDY, BRENT SHELDON (DPT)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:SHELDON
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2335 PTARMIGAN WAY
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5850
Mailing Address - Country:US
Mailing Address - Phone:208-552-5661
Mailing Address - Fax:
Practice Address - Street 1:3715 WOODKING DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4720
Practice Address - Country:US
Practice Address - Phone:208-529-2255
Practice Address - Fax:208-529-2022
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRPT-1740225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806757200Medicaid
ID1654840Medicare PIN