Provider Demographics
NPI:1730103821
Name:KENNEDY, DAVID (PT,MS,CCS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:PT,MS,CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 HIGHWAY 314 SW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-9600
Mailing Address - Country:US
Mailing Address - Phone:505-866-0055
Mailing Address - Fax:
Practice Address - Street 1:1220 CAMINO DEL LLANO
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-2727
Practice Address - Country:US
Practice Address - Phone:505-861-1200
Practice Address - Fax:505-861-1220
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2251225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1245380039OtherBERNALILLO FACILITY NPI
NM1356491146OtherBELEN FACILITY NPI
NM1386651412OtherLOS LUNAS FACILITY NPI
NM000Q0406OtherMEDICAID GROUP #
NM2251OtherNM STATE LICENSE
NM13201271Medicaid
NMP00167482OtherRAILROAD MEDICARE
NM2251OtherNM STATE LICENSE
NM900521078Medicare UPIN