Provider Demographics
NPI:1528033909
Name:KENSINGTON VALLEY ORTHOTIC & SPORTS SERVICES
Entity Type:Organization
Organization Name:KENSINGTON VALLEY ORTHOTIC & SPORTS SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:QUENTIN
Authorized Official - Last Name:MINERT
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:810-231-6905
Mailing Address - Street 1:PO BOX 215
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:MI
Mailing Address - Zip Code:48139-0215
Mailing Address - Country:US
Mailing Address - Phone:810-231-6905
Mailing Address - Fax:801-231-6906
Practice Address - Street 1:10020 PROFESSIONAL CANTER DR.
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:MI
Practice Address - Zip Code:48139-0215
Practice Address - Country:US
Practice Address - Phone:810-231-6905
Practice Address - Fax:810-231-6906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4489299Medicaid
MI510D703120OtherBLUE CROSS BLUE SHIELD MI