1417024548 NPI number — KENMAR RESIDENTIAL SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417024548 NPI number — KENMAR RESIDENTIAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENMAR RESIDENTIAL SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417024548
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33 CYPRESS BLVD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROUND ROCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78665-1006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-658-5959
Provider Business Mailing Address Fax Number:
512-336-0812

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1609 MALLARD LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAYLOR
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76574-5026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-336-0800
Provider Business Practice Location Address Fax Number:
512-336-0812
Provider Enumeration Date:
11/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRAY
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
KENNETH
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
512-336-0800

Provider Taxonomy Codes

  • Taxonomy code: 320900000X , with the licence number:  117374 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 45H155 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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