Provider Demographics
NPI:1871831453
Name:KENWORTHY, KEITH GLENN (LVN,PHLEBOTOMIST)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:GLENN
Last Name:KENWORTHY
Suffix:
Gender:M
Credentials:LVN,PHLEBOTOMIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1764 N ORANGE DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-4307
Mailing Address - Country:US
Mailing Address - Phone:323-491-4765
Mailing Address - Fax:
Practice Address - Street 1:1764 N ORANGE DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-4307
Practice Address - Country:US
Practice Address - Phone:323-491-4765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 267760164X00000X
CACPT00040181246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No164X00000XNursing Service ProvidersLicensed Vocational Nurse