Provider Demographics
NPI:1376168054
Name:QUALLS, KEN E (SA-C)
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:E
Last Name:QUALLS
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 BELLAIRE AVE
Mailing Address - Street 2:
Mailing Address - City:DUMAS
Mailing Address - State:TX
Mailing Address - Zip Code:79029-3321
Mailing Address - Country:US
Mailing Address - Phone:806-338-1228
Mailing Address - Fax:
Practice Address - Street 1:224 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DUMAS
Practice Address - State:TX
Practice Address - Zip Code:79029-3808
Practice Address - Country:US
Practice Address - Phone:806-935-7171
Practice Address - Fax:806-935-9702
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20-226246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant