Individual
KENNETH GENE SEBRERO LACANDAZO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
26 2ND ST, MONTEAGLE, TN 37356-7415
(932) 924-2041
Mailing address
26 2ND ST, MONTEAGLE, TN 37356-7415
Taxonomy
Speciality
Code
Description
License number
State
208100000X
Physical Medicine & Rehabilitation Physician
Primary
11420
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
137911973
DRIVER'S LICENSE
TN
Enumeration date
04/22/2020
Last updated
04/22/2020
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