Provider Demographics
NPI:1578181590
Name:GARCIA, KENNETH JAMES TALLADA (CPO)
Entity Type:Individual
Prefix:
First Name:KENNETH JAMES
Middle Name:TALLADA
Last Name:GARCIA
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:KEN
Other - Middle Name:T
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CPO
Mailing Address - Street 1:100 EMANCIPATION DR PROSTHETICS DEPT
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23667-0001
Mailing Address - Country:US
Mailing Address - Phone:757-722-9961
Mailing Address - Fax:
Practice Address - Street 1:100 EMANCIPATION DR PROSTHETICS DEPT
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23667-0001
Practice Address - Country:US
Practice Address - Phone:757-722-9961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist