Provider Demographics
NPI:1811713431
Name:MERCADO, KENNETH (PT, DPT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:MERCADO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KENNY
Other - Middle Name:
Other - Last Name:MERCADO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:1836 KAOHU ST
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-2310
Mailing Address - Country:US
Mailing Address - Phone:732-500-8714
Mailing Address - Fax:
Practice Address - Street 1:81 MAKAWAO AVE STE 110
Practice Address - Street 2:
Practice Address - City:MAKAWAO
Practice Address - State:HI
Practice Address - Zip Code:96768-8859
Practice Address - Country:US
Practice Address - Phone:808-572-2281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-27
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT-6055225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist