Provider Demographics
NPI:1912281841
Name:YATES, KENNETH MICHAEL
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:YATES
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 1:16203 COURTHOUSE RD
Mailing Address - Street 2:DINWIDDIE
Mailing Address - City:DINWIDDIE
Mailing Address - State:VA
Mailing Address - Zip Code:23841-3431
Mailing Address - Country:US
Mailing Address - Phone:804-721-4176
Mailing Address - Fax:
Practice Address - Street 1:16203 COURTHOUSE RD
Practice Address - Street 2:DINWIDDIE
Practice Address - City:DINWIDDIE
Practice Address - State:VA
Practice Address - Zip Code:23841-3431
Practice Address - Country:US
Practice Address - Phone:804-721-4176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2705-062531C171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications