Provider Demographics
NPI:1508998337
Name:KOMENDA, KEVIN JAMES
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JAMES
Last Name:KOMENDA
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 1:3409 MCNAIR DR N
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-3740
Mailing Address - Country:US
Mailing Address - Phone:763-529-9182
Mailing Address - Fax:
Practice Address - Street 1:800 E 28TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3723
Practice Address - Country:US
Practice Address - Phone:612-863-9190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6926225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist