Provider Demographics
NPI:1962655225
Name:JAVINES, KENNETH DAMICOG
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DAMICOG
Last Name:JAVINES
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 1:3033 32ND ST
Mailing Address - Street 2:2F
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-1985
Mailing Address - Country:US
Mailing Address - Phone:646-288-5840
Mailing Address - Fax:
Practice Address - Street 1:3033 32ND ST
Practice Address - Street 2:2F
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-1985
Practice Address - Country:US
Practice Address - Phone:646-288-5840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0242641225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist