Provider Demographics
NPI:1346829454
Name:WENTZEL, KEVIN M (CRM)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:WENTZEL
Suffix:
Gender:M
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:389 SW SCALEHOUSE CT STE 130
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3241
Mailing Address - Country:US
Mailing Address - Phone:541-777-7847
Mailing Address - Fax:541-512-7090
Practice Address - Street 1:125 SW C ST
Practice Address - Street 2:
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741-1458
Practice Address - Country:US
Practice Address - Phone:541-777-7847
Practice Address - Fax:541-512-7090
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21-CRM-442175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR21-CRM-442OtherMHACBO