1639108236 NPI number — MR. KENNETH A WOODARD JR. MS,LAT,ATC,PES,CES

Table of content: MR. KENNETH A WOODARD JR. MS,LAT,ATC,PES,CES (NPI 1639108236)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639108236 NPI number — MR. KENNETH A WOODARD JR. MS,LAT,ATC,PES,CES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOODARD
Provider First Name:
KENNETH
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MS,LAT,ATC,PES,CES
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:
1639108236
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
211 REDBIRD LN
Provider Second Line Business Mailing Address:
CAMPUS BOX 10611/ATHLETIC TRAINING
Provider Business Mailing Address City Name:
BEAUMONT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77705-9801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-880-7394
Provider Business Mailing Address Fax Number:
409-880-2366

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
211 REDBIRD LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAUMONT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77705-9801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-880-7394
Provider Business Practice Location Address Fax Number:
409-880-2366
Provider Enumeration Date:
07/03/2006

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: 2255A2300X , with the licence number:  AT6526 , 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)





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