Provider Demographics
NPI:1184773954
Name:SMITH, KENNETH W (PT)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:W
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 NE ELM ST
Mailing Address - Street 2:STE 2-A
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-1206
Mailing Address - Country:US
Mailing Address - Phone:541-447-6846
Mailing Address - Fax:541-447-1243
Practice Address - Street 1:1251 NE ELM ST
Practice Address - Street 2:STE 2-A
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-1206
Practice Address - Country:US
Practice Address - Phone:541-447-6846
Practice Address - Fax:541-447-1243
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0963225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR160010Medicaid
ORR00WFBCGAMedicare PIN
OR160010Medicaid