Provider Demographics
NPI:1891417580
Name:SHAW, KENNETH (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:362 GRANDVIEW ST
Mailing Address - Street 2:
Mailing Address - City:CHURCH HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37642-3828
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1350 KING COLLEGE RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-2632
Practice Address - Country:US
Practice Address - Phone:800-362-0014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29942255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer