Provider Demographics
NPI:1740266899
Name:KENNETH C PRUYN JR
Entity type:Organization
Organization Name:KENNETH C PRUYN JR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:C
Authorized Official - Last Name:PRUYN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:800-652-6683
Mailing Address - Street 1:35 ARMSTRONG CT
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02324-2283
Mailing Address - Country:US
Mailing Address - Phone:800-652-6683
Mailing Address - Fax:508-697-5015
Practice Address - Street 1:35 ARMSTRONG CT
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02324-2283
Practice Address - Country:US
Practice Address - Phone:800-652-6683
Practice Address - Fax:508-697-5015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-21
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA316454OtherBLUE CROSS PROVIDER
MA1538136Medicaid
MA316454OtherBLUE CROSS PROVIDER