Provider Demographics
NPI:1356621536
Name:CHANNER, KENNETH DANIEL (DPT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:DANIEL
Last Name:CHANNER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N COLLEGE DR
Mailing Address - Street 2:STE. 203
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-4614
Mailing Address - Country:US
Mailing Address - Phone:805-922-1724
Mailing Address - Fax:805-922-2765
Practice Address - Street 1:201 N COLLEGE DR
Practice Address - Street 2:STE. 203
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-4614
Practice Address - Country:US
Practice Address - Phone:805-922-1724
Practice Address - Fax:805-922-2765
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT37157174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFO856ZOtherMEDICARE-PTAN
CAF0856YOtherMEDICARE-PTAN