Provider Demographics
NPI:1265050330
Name:MCLENDON, KURTIS
Entity type:Individual
Prefix:
First Name:KURTIS
Middle Name:
Last Name:MCLENDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KURTIS
Other - Middle Name:
Other - Last Name:JEWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6281 MARSH WREN DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43230-6533
Mailing Address - Country:US
Mailing Address - Phone:419-961-5104
Mailing Address - Fax:
Practice Address - Street 1:6281 MARSH WREN DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43230-6533
Practice Address - Country:US
Practice Address - Phone:419-961-5104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-06
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2573275172A00000X, 251X00000X, 343900000X, 3747P1801X, 376J00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No172A00000XOther Service ProvidersDriver
No251X00000XAgenciesSupports Brokerage
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2573275Medicaid
OH0312797Medicaid