Provider Demographics
NPI:1801463484
Name:SANCHEZ, KENNETE JUAN
Entity type:Individual
Prefix:
First Name:KENNETE
Middle Name:JUAN
Last Name:SANCHEZ
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 1:4943 S RAYFORD CIR
Mailing Address - Street 2:
Mailing Address - City:KEARNS
Mailing Address - State:UT
Mailing Address - Zip Code:84118-7226
Mailing Address - Country:US
Mailing Address - Phone:801-814-2262
Mailing Address - Fax:
Practice Address - Street 1:7613 S JORDAN LANDING BLVD STE 200
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-1973
Practice Address - Country:US
Practice Address - Phone:801-613-9843
Practice Address - Fax:385-213-6087
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
324500000X
UT1492175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility