Provider Demographics
NPI:1760980478
Name:BEDFORD, KEVIN NEIL (LMT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:NEIL
Last Name:BEDFORD
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8387 SENECA TPKE
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-4957
Mailing Address - Country:US
Mailing Address - Phone:315-794-9554
Mailing Address - Fax:
Practice Address - Street 1:8387 SENECA TPKE
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-4957
Practice Address - Country:US
Practice Address - Phone:315-794-9554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-28
Last Update Date:2018-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011536225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist