Provider Demographics
NPI:1780074591
Name:DRAKE, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:DRAKE
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 1:563 BAKEMAN LN
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-3752
Mailing Address - Country:US
Mailing Address - Phone:805-710-9184
Mailing Address - Fax:
Practice Address - Street 1:1124 NIPOMO ST STE C
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3883
Practice Address - Country:US
Practice Address - Phone:805-202-1492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0002004171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist