Provider Demographics
NPI:1952006629
Name:KENFACK DJOUAKA, MODESTE R
Entity Type:Individual
Prefix:
First Name:MODESTE
Middle Name:R
Last Name:KENFACK DJOUAKA
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 1:1101 THORPE LN # 105-520
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-7105
Mailing Address - Country:US
Mailing Address - Phone:512-361-1247
Mailing Address - Fax:
Practice Address - Street 1:1101 THORPE LN # 105-520
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7105
Practice Address - Country:US
Practice Address - Phone:512-361-1247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)