Provider Demographics
NPI:1245466101
Name:SLODOWSKI, KENNETH P (MMT,LMT,)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:P
Last Name:SLODOWSKI
Suffix:
Gender:M
Credentials:MMT,LMT,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6722 YATESVILLE HWY LOT 8
Mailing Address - Street 2:
Mailing Address - City:YATESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31097-3840
Mailing Address - Country:US
Mailing Address - Phone:478-297-6759
Mailing Address - Fax:
Practice Address - Street 1:6722 YATESVILLE HWY LOT 8
Practice Address - Street 2:
Practice Address - City:YATESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31097-3840
Practice Address - Country:US
Practice Address - Phone:478-297-6759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-05
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0284225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist