Organization
PRO OF KENNETT, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. TENA R. VANDEVENTER (OFFICE MANAGER)
(573) 888-9190
Entity
Organization
Contact information
Practice address
306 RECOVERY RD, KENNETT, MO 63857-3267
(573) 888-9190
(573) 888-9404
Mailing address
306 RECOVERY RD, KENNETT, MO 63857-3267
(573) 888-9190
(573) 888-9404
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
01506
MO
174400000X
Specialist
02042
MO
174400000X
Specialist
Primary
R0582
MO
235Z00000X
Speech-Language Pathologist
107027
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1144278201
INDIVIDUAL NPI #
—
01
—
1205884335
INDIVIDUAL NPI #
—
01
—
1639127186
INDIVIDUAL NPI #
—
01
—
1710935176
INDIVIDUAL NPI #
—
Enumeration date
05/24/2007
Last updated
11/15/2007
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