Provider Demographics
NPI:1649706326
Name:SQUIRES, KENNETH EDWARD III (DO)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:EDWARD
Last Name:SQUIRES
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:KENNY
Other - Middle Name:
Other - Last Name:SQUIRES
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:6348 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8732
Practice Address - Country:US
Practice Address - Phone:208-302-0900
Practice Address - Fax:208-302-0955
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPG1830592084P0800X
IDO-19782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry