Basic Information
| Provider Information | |||||||||
| NPI: | 1013087063 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | OTHER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 MILES ST | ||||||||
| Address2: | |||||||||
| City: | BROKEN BOW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747284507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802365261 | ||||||||
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| Practice Location | |||||||||
| Address1: | 902 E LINCOLN RD | ||||||||
| Address2: | |||||||||
| City: | IDABEL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747457337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802862600 | ||||||||
| FaxNumber: | 5802861107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 06/07/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1117 | AK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1117 | 01 | AK | PHYSICAL THERAPY | OTHER | 4463 | 01 | OK | OKLAHOMA PT LICENSE | OTHER |