Provider Demographics
NPI:1568883429
Name:KENNEBUNK FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:KENNEBUNK FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:CECILY
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-229-5789
Mailing Address - Street 1:103 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:KENNEBUNK
Mailing Address - State:ME
Mailing Address - Zip Code:04043-6613
Mailing Address - Country:US
Mailing Address - Phone:207-229-5789
Mailing Address - Fax:207-502-7221
Practice Address - Street 1:9 HIGH ST
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-7164
Practice Address - Country:US
Practice Address - Phone:207-502-7220
Practice Address - Fax:207-502-7220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-19
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME2043261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center