1659409126 NPI number — MR. KENNETH WAYNE RUBENACKER M.S., CCC-A

Table of content: MR. KENNETH WAYNE RUBENACKER M.S., CCC-A (NPI 1659409126)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659409126 NPI number — MR. KENNETH WAYNE RUBENACKER M.S., CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUBENACKER
Provider First Name:
KENNETH
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.S., CCC-A
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:
1659409126
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
417 S KINGSHIGHWAY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIKESTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63801-2923
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-471-7264
Provider Business Mailing Address Fax Number:
573-471-7264

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
417 SOUTH KINGSHIGHWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIKESTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63801-2923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-471-7264
Provider Business Practice Location Address Fax Number:
573-471-7264
Provider Enumeration Date:
02/28/2007

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: 231H00000X , with the licence number:  01570 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 237700000X , with the licence number: 000803 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 45-00333 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 121820 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 531661 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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