Provider Demographics
NPI:1881076560
Name:DIKE KENNETH
Entity type:Organization
Organization Name:DIKE KENNETH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:DIKE
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:508-631-8222
Mailing Address - Street 1:15 BERGERON WAY
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072
Mailing Address - Country:US
Mailing Address - Phone:617-967-2115
Mailing Address - Fax:
Practice Address - Street 1:15 BERGERON WAY
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-1392
Practice Address - Country:US
Practice Address - Phone:508-631-8222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service