1558039172 NPI number — BREANNA I KENDER ATC

Table of content: BREANNA I KENDER ATC (NPI 1558039172)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558039172 NPI number — BREANNA I KENDER ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENDER
Provider First Name:
BREANNA
Provider Middle Name:
I
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1558039172
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
63 SCARBOROUGH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BREWSTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02631-2816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 UNIVERSITY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RINDGE
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03461-5046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-899-4357
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: XXH983760398 . This is a "BLUE CROSS BLUE SHIELD CARD" identifier . This identifiers is of the category "OTHER".




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