1821055047 NPI number — MR. KENNETH JOHN BANNON BSPA-C

Table of content: MR. KENNETH JOHN BANNON BSPA-C (NPI 1821055047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821055047 NPI number — MR. KENNETH JOHN BANNON BSPA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BANNON
Provider First Name:
KENNETH
Provider Middle Name:
JOHN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
BSPA-C
Provider Gender Code:
M

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:
1821055047
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 PARK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HONESDALE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18431-1445
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:
111 SALEM AVENUE
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
CARBONDALE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18407-2574
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-282-2031
Provider Business Practice Location Address Fax Number:
570-282-2534
Provider Enumeration Date:
05/01/2006

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: 363A00000X , with the licence number:  MA001023L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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