Provider Demographics
NPI:1417900309
Name:BREEDEN, KENNETH E (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:E
Last Name:BREEDEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6703 W RIO GRANDE AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-2623
Mailing Address - Country:US
Mailing Address - Phone:509-460-5588
Mailing Address - Fax:509-783-5438
Practice Address - Street 1:965 GOETHALS DR
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3527
Practice Address - Country:US
Practice Address - Phone:509-460-5588
Practice Address - Fax:509-783-5438
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000102991223G0001X
WAOP00001987171100000X, 207L00000X, 208VP0014X, 207LP2900X, 207Q00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No1223G0001XDental ProvidersDentistGeneral Practice
No171100000XOther Service ProvidersAcupuncturist
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1009897Medicaid
WAP01344361OtherRR MEDICARE
WA8434599Medicaid
WAG8855592Medicare PIN
WAG8926435Medicare PIN
WA8434599Medicaid