Provider Demographics
NPI:1679335152
Name:BROWN, KENNETH JR (N/A)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:BROWN
Suffix:JR
Gender:M
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 63
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72303-0063
Mailing Address - Country:US
Mailing Address - Phone:870-394-9711
Mailing Address - Fax:
Practice Address - Street 1:310 MID CONTINENT PLZ STE 616
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-1760
Practice Address - Country:US
Practice Address - Phone:870-394-9711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program