Provider Demographics
NPI:1396841300
Name:DIEHL, KENNETH LEE (PT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEE
Last Name:DIEHL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 28
Mailing Address - Street 2:
Mailing Address - City:KEALAKEKUA
Mailing Address - State:HI
Mailing Address - Zip Code:96750-0028
Mailing Address - Country:US
Mailing Address - Phone:520-241-7403
Mailing Address - Fax:
Practice Address - Street 1:75-5699 KOPIKO ST
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-1668
Practice Address - Country:US
Practice Address - Phone:808-329-7744
Practice Address - Fax:808-334-1608
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2567225100000X
AZ3925225100000X
NM3101225100000X
AK1513225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI26271OtherHMSA QUEST
HI591314Medicaid
HI26271OtherHMSA BC/BS
AZP39509Medicare UPIN
HI26271OtherHMSA BC/BS