Provider Demographics
NPI:1245661404
Name:LONGO, KENDELL
Entity type:Individual
Prefix:
First Name:KENDELL
Middle Name:
Last Name:LONGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7A SPOFFORD RD
Mailing Address - Street 2:
Mailing Address - City:BOXFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01921-1501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7A SPOFFORD ROAD
Practice Address - Street 2:
Practice Address - City:BOXFORD
Practice Address - State:MA
Practice Address - Zip Code:01921
Practice Address - Country:US
Practice Address - Phone:978-887-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service