Provider Demographics
NPI:1831529239
Name:STACKER, KENDALL C
Entity type:Individual
Prefix:MR
First Name:KENDALL
Middle Name:C
Last Name:STACKER
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 1:2745 BROOKMEADOW DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221
Mailing Address - Country:US
Mailing Address - Phone:618-257-3090
Mailing Address - Fax:618-257-3090
Practice Address - Street 1:2745 BROOKMEADOW DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-7116
Practice Address - Country:US
Practice Address - Phone:618-257-3090
Practice Address - Fax:618-257-3090
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-21
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
343900000X
IL343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)