Provider Demographics
NPI:1972098184
Name:STREET, KENDERICK RENARD JR (IDC)
Entity Type:Individual
Prefix:MR
First Name:KENDERICK
Middle Name:RENARD
Last Name:STREET
Suffix:JR
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 TOWNSEND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06512-3653
Mailing Address - Country:US
Mailing Address - Phone:912-331-3110
Mailing Address - Fax:
Practice Address - Street 1:503 TOWNSEND AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06512-3653
Practice Address - Country:US
Practice Address - Phone:912-331-3110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-29
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other