Provider Demographics
NPI:1679858823
Name:KENNEDY, BRIAN JOSEPH
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JOSEPH
Last Name:KENNEDY
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 1:825 SIERRA VISTA DR
Mailing Address - Street 2:APT #225
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89169-9384
Mailing Address - Country:US
Mailing Address - Phone:858-386-3435
Mailing Address - Fax:
Practice Address - Street 1:825 SIERRA VISTA DR
Practice Address - Street 2:APT #225
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-9384
Practice Address - Country:US
Practice Address - Phone:858-386-3435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1604166640225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner