Provider Demographics
NPI:1871039081
Name:SANDERS, KENNETH DEAN (CADC CAS)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DEAN
Last Name:SANDERS
Suffix:
Gender:M
Credentials:CADC CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3107 E KAWEAH AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93292-3309
Mailing Address - Country:US
Mailing Address - Phone:559-754-2705
Mailing Address - Fax:559-754-2708
Practice Address - Street 1:3107 E KAWEAH AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93292-3309
Practice Address - Country:US
Practice Address - Phone:559-754-2705
Practice Address - Fax:559-754-2708
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-11
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC29611214324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC29611214OtherCCAPP