Provider Demographics
NPI:1245467554
Name:SAMUEL, KENNY E
Entity type:Individual
Prefix:MR
First Name:KENNY
Middle Name:E
Last Name:SAMUEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DISTINCTIVE
Other - Middle Name:CARE
Other - Last Name:TRANSPORTATION COMPANY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 090374
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-0374
Mailing Address - Country:US
Mailing Address - Phone:414-406-1438
Mailing Address - Fax:414-353-5633
Practice Address - Street 1:6621 N YUBA ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-5759
Practice Address - Country:US
Practice Address - Phone:414-406-1438
Practice Address - Fax:414-353-5633
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-12
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41488300343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)