Provider Demographics
NPI:1710167804
Name:PRUYN, KENNETH CHARLES JR
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:CHARLES
Last Name:PRUYN
Suffix:JR
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 1:20 BEAVER POND RD STE 201
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757-3743
Mailing Address - Country:US
Mailing Address - Phone:508-794-3620
Mailing Address - Fax:508-205-0291
Practice Address - Street 1:67 FOREST ST STE 350-25
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-3195
Practice Address - Country:US
Practice Address - Phone:508-794-3620
Practice Address - Fax:508-205-0291
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2025-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA254237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1538136Medicaid
MA316454OtherBLUECROSS
MA0730090001Medicare NSC