1912075318 NPI number — KENMAR RESIDENTIAL SERVICES

Table of content: (NPI 1912075318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912075318 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:
1912075318
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:
512-336-0800
Provider Business Mailing Address Fax Number:
512-336-0812

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1426 N RUDDELL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76209-3336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-566-4961
Provider Business Practice Location Address Fax Number:
940-566-2371
Provider Enumeration Date:
12/01/2006

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:  115066 , 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: 45H242 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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