Provider Demographics
NPI:1629424684
Name:AMOO, KENNETH
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:AMOO
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 1:10737 TUTTLE LN
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:VA
Mailing Address - Zip Code:20136-2803
Mailing Address - Country:US
Mailing Address - Phone:973-280-2123
Mailing Address - Fax:703-594-0224
Practice Address - Street 1:10737 TUTTLE LN
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:VA
Practice Address - Zip Code:20136-2803
Practice Address - Country:US
Practice Address - Phone:973-280-2123
Practice Address - Fax:703-594-0224
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-09
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA331172A00000X
343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA331OtherNON-EMERGENCY MEDICAL TRANSPORTATION CARRIER