Provider Demographics
NPI:1942854443
Name:RUSH, KENNETH
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:RUSH
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 1:7907 SO. RHODES AVE.
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619
Mailing Address - Country:US
Mailing Address - Phone:773-987-6538
Mailing Address - Fax:
Practice Address - Street 1:7907 S RHODES AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-3019
Practice Address - Country:US
Practice Address - Phone:773-987-6538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227009717225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist