Provider Demographics
NPI:1902584451
Name:MWANDA, KENNEDY OPIYO
Entity Type:Individual
Prefix:MR
First Name:KENNEDY
Middle Name:OPIYO
Last Name:MWANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 W MILHAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-1029
Mailing Address - Country:US
Mailing Address - Phone:269-929-8436
Mailing Address - Fax:
Practice Address - Street 1:3320 W MILHAM AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-1029
Practice Address - Country:US
Practice Address - Phone:269-929-8436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS390410848311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home