Provider Demographics
NPI:1790712552
Name:WARREN, KENNETH CHRISTIAN (PT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:CHRISTIAN
Last Name:WARREN
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 1:285 WOODGROVE DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30605-7510
Mailing Address - Country:US
Mailing Address - Phone:706-296-0334
Mailing Address - Fax:
Practice Address - Street 1:665 GAINES SCHOOL RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605-3127
Practice Address - Country:US
Practice Address - Phone:706-369-8115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007957225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBCXGMedicare ID - Type Unspecified
GAQ41529Medicare UPIN