Basic Information
| Provider Information | |||||||||
| NPI: | 1811589393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POCOCK | ||||||||
| FirstName: | KENNEDY | ||||||||
| MiddleName: | |||||||||
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| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 268 BUSH ST STE 3039 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941043503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883623970 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10807 W NORTHERN AVE | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853071758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282102857 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2021 | ||||||||
| LastUpdateDate: | 02/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | RBT-20-148347 | 01 | RBT | OTHER |