Provider Demographics
NPI:1922268788
Name:KENNEDY, KEVIN P (CP)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:P
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:KEVIN
Other - Middle Name:
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:KEVIN KENNEDY CP&O
Mailing Address - Street 1:551 S BOLLING RD
Mailing Address - Street 2:
Mailing Address - City:PAHRUMP
Mailing Address - State:NV
Mailing Address - Zip Code:89048-4642
Mailing Address - Country:US
Mailing Address - Phone:702-468-2376
Mailing Address - Fax:702-823-1336
Practice Address - Street 1:1100 GARDEN HWY.
Practice Address - Street 2:STE. 900
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-7598
Practice Address - Country:US
Practice Address - Phone:530-673-6913
Practice Address - Fax:530-671-6915
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-13
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKABCCP003164BOCC155661744P3200X
224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management