Provider Demographics
NPI:1639182876
Name:KENNEDY, PAUL R (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:R
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9620 COMANCHE MOON DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521-5144
Mailing Address - Country:US
Mailing Address - Phone:702-767-7424
Mailing Address - Fax:
Practice Address - Street 1:925 TAHOE BLVD STE 105
Practice Address - Street 2:
Practice Address - City:INCLINE VILLAGE
Practice Address - State:NV
Practice Address - Zip Code:89451-7498
Practice Address - Country:US
Practice Address - Phone:775-580-7602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV05060332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer