Provider Demographics
NPI:1356922538
Name:FENIK, KENNETH J
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:FENIK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 LINDSAY CT
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-8857
Mailing Address - Country:US
Mailing Address - Phone:440-213-3822
Mailing Address - Fax:
Practice Address - Street 1:127 LINDSAY CT
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-8857
Practice Address - Country:US
Practice Address - Phone:440-213-3822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRJ870797172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver