Provider Demographics
NPI:1417371378
Name:ROPER, KEN
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:ROPER
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 1:55907 WOOD DUCK DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97707-2344
Mailing Address - Country:US
Mailing Address - Phone:541-771-9542
Mailing Address - Fax:
Practice Address - Street 1:55907 WOOD DUCK DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97707-2344
Practice Address - Country:US
Practice Address - Phone:541-771-9542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1593248-4172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1593249-4OtherFEIN 46-4678412