Provider Demographics
NPI:1811108608
Name:PRO OF KENNETT, INC.
Entity type:Organization
Organization Name:PRO OF KENNETT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TENA
Authorized Official - Middle Name:R
Authorized Official - Last Name:VANDEVENTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-888-9190
Mailing Address - Street 1:306 RECOVERY RD
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-3267
Mailing Address - Country:US
Mailing Address - Phone:573-888-9190
Mailing Address - Fax:573-888-9404
Practice Address - Street 1:306 RECOVERY RD
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-3267
Practice Address - Country:US
Practice Address - Phone:573-888-9190
Practice Address - Fax:573-888-9404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO02042174400000X
MO01506174400000X
MO107027235Z00000X
MOR0582174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1639127186OtherINDIVIDUAL NPI #
1144278201OtherINDIVIDUAL NPI #
1205884335OtherINDIVIDUAL NPI #
1710935176OtherINDIVIDUAL NPI #