Provider Demographics
NPI:1710316047
Name:SPAULDING, KENNETH (PTA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:SPAULDING
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 E 16TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-9127
Mailing Address - Country:US
Mailing Address - Phone:616-396-7095
Mailing Address - Fax:616-396-7157
Practice Address - Street 1:1221 E 16TH ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-9127
Practice Address - Country:US
Practice Address - Phone:616-396-7095
Practice Address - Fax:616-396-7157
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2262582225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant