Provider Demographics
NPI:1710182464
Name:RODEMAN, KENNETH J (PT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:RODEMAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3622 NE WEST DEVILS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97367-5039
Mailing Address - Country:US
Mailing Address - Phone:307-250-2554
Mailing Address - Fax:
Practice Address - Street 1:3043 NE 28TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-4518
Practice Address - Country:US
Practice Address - Phone:541-996-7160
Practice Address - Fax:541-996-7223
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-302225100000X
OR1793225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist