Provider Demographics
NPI:1437286937
Name:KENBECK LLC
Entity Type:Organization
Organization Name:KENBECK LLC
Other - Org Name:THE LIGHT THERAPY INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SOFIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-491-3103
Mailing Address - Street 1:4342 E TRADEWINDS AVE
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE BY THE SEA
Mailing Address - State:FL
Mailing Address - Zip Code:33308-5044
Mailing Address - Country:US
Mailing Address - Phone:954-491-3103
Mailing Address - Fax:
Practice Address - Street 1:4342 E TRADEWINDS AVE
Practice Address - Street 2:
Practice Address - City:LAUDERDALE BY THE SEA
Practice Address - State:FL
Practice Address - Zip Code:33308-5044
Practice Address - Country:US
Practice Address - Phone:954-491-3103
Practice Address - Fax:954-491-3105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Multi-Specialty