Provider Demographics
NPI:1790789196
Name:KENNY, MARK F (CPO)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:F
Last Name:KENNY
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:MR
Other - First Name:ANTHONY
Other - Middle Name:J
Other - Last Name:SQUICCIARINI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CPO CPED
Mailing Address - Street 1:66 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOBBS FERRY
Mailing Address - State:NY
Mailing Address - Zip Code:10522-2159
Mailing Address - Country:US
Mailing Address - Phone:914-479-0743
Mailing Address - Fax:914-479-1568
Practice Address - Street 1:66 MAIN ST
Practice Address - Street 2:
Practice Address - City:DOBBS FERRY
Practice Address - State:NY
Practice Address - Zip Code:10522-2159
Practice Address - Country:US
Practice Address - Phone:914-479-0743
Practice Address - Fax:914-479-1568
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022001744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02215167Medicaid
NY02215167Medicaid