Basic Information
| Provider Information | |||||||||
| NPI: | 1184128118 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KERN | ||||||||
| FirstName: | CODY | ||||||||
| MiddleName: | DYLAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 213 HIGH RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637368140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733822331 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 S LIMESTONE CTW 304 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405360001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593239918 | ||||||||
| FaxNumber: | 8593231197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2018 | ||||||||
| LastUpdateDate: | 03/23/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | 193400000X SINGLE SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.