Provider Demographics
NPI:1942630116
Name:WIDEMON, KENDRICK
Entity Type:Individual
Prefix:
First Name:KENDRICK
Middle Name:
Last Name:WIDEMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 COTTONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:TX
Mailing Address - Zip Code:76036-4308
Mailing Address - Country:US
Mailing Address - Phone:903-830-7993
Mailing Address - Fax:
Practice Address - Street 1:5728 MOON FLOWER CT
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76244
Practice Address - Country:US
Practice Address - Phone:817-337-9548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1172043225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist