Basic Information
| Provider Information | |||||||||
| NPI: | 1528033909 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENSINGTON VALLEY ORTHOTIC & SPORTS SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 215 | ||||||||
| Address2: | |||||||||
| City: | HAMBURG | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481390215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102316905 | ||||||||
| FaxNumber: | 8012316906 | ||||||||
| Practice Location | |||||||||
| Address1: | 10020 PROFESSIONAL CANTER DR. | ||||||||
| Address2: | |||||||||
| City: | HAMBURG | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481390215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102316905 | ||||||||
| FaxNumber: | 8102316906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 04/13/2011 | ||||||||
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| AuthorizedOfficialLastName: | MINERT | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | QUENTIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8102316905 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | C.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | Y | Suppliers | Prosthetic/Orthotic Supplier |
ID Information
| ID | Type | State | Issuer | Description | 4489299 | 05 | MI | MEDICAID | 510D703120 | 01 | MI | BLUE CROSS BLUE SHIELD MI | OTHER |