Provider Demographics
NPI:1356012462
Name:VINACCO, KENNETH LOUIS (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LOUIS
Last Name:VINACCO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 COMMONWEALTH AVE REAR
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-1394
Mailing Address - Country:US
Mailing Address - Phone:617-358-3700
Mailing Address - Fax:866-818-0863
Practice Address - Street 1:635 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1605
Practice Address - Country:US
Practice Address - Phone:617-358-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA25661225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist