Basic Information
| Provider Information | |||||||||
| NPI: | 1245754456 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MYNATT | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1459 MONTREAL RD STE 304 | ||||||||
| Address2: | |||||||||
| City: | TUCKER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300846920 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1459 MONTREAL RD STE 304 | ||||||||
| Address2: | |||||||||
| City: | TUCKER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300846920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042513420 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2017 | ||||||||
| LastUpdateDate: | 07/29/2017 | ||||||||
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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 | 208100000X | PT013026 | GA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.