Provider Demographics
NPI:1891841540
Name:CORDOVA, KENNETH J (MOTRL)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:CORDOVA
Suffix:
Gender:M
Credentials:MOTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 53363
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87153-3363
Mailing Address - Country:US
Mailing Address - Phone:505-730-9540
Mailing Address - Fax:505-332-3043
Practice Address - Street 1:2916 DOROTHY ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-1619
Practice Address - Country:US
Practice Address - Phone:505-244-4175
Practice Address - Fax:505-332-3043
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2214225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM46131264Medicaid