Provider Demographics
NPI:1710167804
Name:PRUYN, KENNETH CHARLES JR
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:CHARLES
Last Name:PRUYN
Suffix:JR
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 1:5 MEADOWLARK DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02346-5401
Mailing Address - Country:US
Mailing Address - Phone:800-652-6683
Mailing Address - Fax:774-213-9002
Practice Address - Street 1:1 REPTON PL UNIT 1401
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-2490
Practice Address - Country:US
Practice Address - Phone:800-652-6683
Practice Address - Fax:774-213-9002
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA254237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1538136Medicaid
MA316454OtherBLUECROSS
MA0730090001Medicare NSC