Provider Demographics
NPI:1134974645
Name:VAN BUREN, KENNETH DANIEL I (CPS)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:DANIEL
Last Name:VAN BUREN
Suffix:I
Gender:M
Credentials:CPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6854 PARKER RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-5313
Mailing Address - Country:US
Mailing Address - Phone:314-286-6988
Mailing Address - Fax:
Practice Address - Street 1:6854 PARKER RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-5313
Practice Address - Country:US
Practice Address - Phone:314-286-6988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO10764175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist